Head Care Client Intake Form

Name

First NameLast Name

Age

Occupation

Gender

Phone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Person

First NameLast Name

Emergency Contact Phone Number

Relationship to the Client

Type of scalp

DryNomalOily

Condition(s) of scalp

DandruffEczemaNone

Massage pressure preference

Light PressureMedium/Normal PressureDeep Pressure

Water pressure preference

HotNormal (Warm)Cold

We provide natural products and essential oils. However, please let us know your preference and sensitivity.

Sensitive to FragranceNot Sensitive

Please let us know your preferred music/sound during a session

Our head spa session includes hot temperatures and acupressure to the head and other body parts. We ask about your medical history and data for your safety and to offer the best services. Please click here if you do not wish to share your medical history.

I do not wish to share my medical history.I hereby release the 3 @Vine Salon and Emi Nakano from any liability for skin damage, and body effects that may result from my decision to refuse to share my medical history.If I have any issue(s) that need to be concern, I will inform the provider directly before the session.

Do you have any of the following conditions?

Do you have any allergies? (ie: food, drug, latex, insect, pet, seasonal) - Please list

Are you pregnant, breastfeed, or nursing? (Female)

YesNo

Are you wearing any implantable medical devices? If yes, what are these devices?

Are you currently taking any medications? If yes, please list them below:

Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:

Were you previously hospitalized? If yes, please indicate when and why:

Special requests. :

By booking, you agree to the following:

1. I give my permission to receive a head spa treatment.

2. I understand that this treatment is not a substitute for traditional medical treatment or medications, and it is not a medical procedure to cure any skin disease such as eczema and psoriasis.

3. I understand that the provider does not diagnose illnesses or injuries or prescribe medications.

4. I understand that this treatment is for relaxation only.

5. I acknowledge that if I have any medical conditions, pregnancy, allergies, or medications (oral or topical) that may be affected by the treatment or services requested, I have the opportunity to discuss such conditions with the service provider. I also have clearance from my physician to receive this treatment.

6. I understand that the risks associated with this treatment include, but are not limited to:

· Superficial bruising

· Short-term muscle soreness

· Exacerbation or undiscovered injury

· I therefore release the company and the individual provider from all liability concerning these injuries that may occur during the session.

7. The company and the individual provider are not responsible for any allergic reactions I experience.

8. I understand the importance of informing my provider of all medical conditions and medications I am taking, and to let the provider know about any changes to these. I understand that there may be additional risks based on my physical condition.

9. I understand that it is my responsibility to inform my provider of any discomfort I may feel during the session so he/she may adjust accordingly.

10. I understand that I or the provider may terminate the session at any time.

11. I have been given a chance to ask questions about the session and my questions have been answered.

12. I understand that cancellations are accepted up to 24 hours before the scheduled services. Within 24 hours of the service, cancellations will be charged 50% of the scheduled cost.

13. I undertand that to secure my appointment, I will submit the payment within 15 days before my booking date.

14. I understand that all services are by appointment only.

15. I understand that free parking spot #5 behind the building (behind white Honda CR-V)

I confirm that all information given in this form is true, complete, and accurate.
I released 3@ Vine Salon and Emi Hair Design Services, LLC for any responsibility in case of accident, illness, or injury.

Signature of the Client

Client /Guardian Name

First NameLast Name

Signature of Client /Guardian

Head Care Client Intake Form

Client Data

Scalp Type

Scalp Condition(s)

Preferred Massage Pressure

Preferred Water Temperature

Hair / Head Care Products Sensitivity

Preffered Music/Sounds

Medical / History

Medical / History Data

Authorization