Client Intake Form
Moonlit Waters Head Spa
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Do you have, or have you had any of the following conditions? Please select from the following:
*
Dandruff
Lice
Hair Loss
Low Blood Pressure
Ring Worm
Claustrophobia
Psoriasis
Seizure Disorder
Epilepsy
Seborrhea
Seborrheic Dermatitis
Excema
Foliculitis
None
Other
Please describe the current status of your scalp.
*
Dry
Normal
Oily
Other
Please list any allergies you may have. If none, answer “N/A.
*
Please list any medications or supplements that you use for scalp/hair care. If none, reply “N/A”.
*
Are you tender headed or do you have a sensitive scalp?
*
Have you ever had a scalp treatment before? If so, please explain your experience:
Please list any scalp/hair care products that you use at home.
*
Do you take anything for hair loss? If so, please explain.
*
Do you have your hair dyed regularly, whether at a salon or at home? If so, how often?
*
Do you have hair extensions? If so, what kind?
*
How did you hear about this salon?
Facebook
Instagram
Referred by a friend
Other
Please list any other instructions, details, or concerns you would like me to know about.
Client Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Print Form
Submit
Submit
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