Scalp Wellness Intake Form

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We cant wait to meet and treat you to our services! This is our old intake form. Please access our NEW Client Intake Form Below.
Scalp Wellness Intake Form
Healthy Hair Starts at the Root—Take Action Today!

Your hair follicles are the foundation of your hair’s vitality, responsible for producing and sustaining growth. With about 100,000 follicles on your scalp alone, their health directly impacts the quality of your hair.

Did you know that scalp conditions like dermatitis, psoriasis, or severe dandruff can damage follicles, leading to thinning hair or even premature hair loss? Clogged follicles, fungal infections, and prolonged use of chemicals or extensions can result in permanent follicle damage if left untreated.

At Dolce Vita Salon, we offer advanced scalp and follicle treatments designed to restore balance, manage scalp conditions, and promote healthy, thriving hair. Don’t wait—protect your scalp and follicles now for stronger, more beautiful hair tomorrow.

Choose Your Scalp Wellness Experience
At Dolce Vita Salon, we offer a variety of tailored scalp treatments designed to nurture your hair and follicle health. Whether you’re seeking pure relaxation or targeted care for specific scalp concerns, our services deliver the results you need in a setting that matches your preferences.

Pure Relaxation – $225 (45 mins)
Indulge in a blissful escape with this calming scalp facial in our private spa room. Lay back on our treatment bed as we address your unique scalp concerns while melting away stress. This 45-minute experience leaves you feeling refreshed and renewed.
**Hair is left to air dry, or add a polished blowdry for an additional charge.

The Crown Renewal – $400 (2 hrs)
Our most elevated service for those seeking in-depth care. Begin with a detailed consultation and dermascope analysis to uncover the root causes of scalp and follicle concerns. Your customized treatment plan includes advanced scalp therapies, product recommendations, and connections to medical providers if needed.
**Includes a polished blowdry finish and high-frequency combing for optimal scalp stimulation.

Essential Scalp Refresh – $325 (1.5 hrs)
Enjoy the transformative care of the Crown Renewal in a shorter session. Perfect for maintaining scalp wellness journey.
**Hair is left to air dry

Customized Scalp Treatment – $165 (1 hr)

A personalized experience tailored to your scalp’s unique needs. This service begins with a consultation and dermascope analysis to assess your scalp’s condition and recommend products. Using a portable steamer, we open follicles for deep cleansing and nourishment. Performed in the salon area, this treatment provides detailed, customized care. **Hair is left to air dry

Express Scalp Treatment – $71 (30 mins)

A 30-minute service ideal for quick, effective scalp care. Performed in the salon area, it includes a relaxing scalp massage with premium oils to stimulate and refresh the scalp. Perfect for fitting into a busy schedule while delivering targeted results. **Hair is left to air dry

To book your appointment:

1. Fill out the essentials below. Please fill out the form in order to ensure the correct sequence of questions appears.

If the service is available to be booked online:
2. You’ll be directed to our online booking portal to schedule your appointment.

If the service is NOT available to be booked online:
3. Our desk expert will reach out to you to schedule your appointment.
Choose your experience.*

Pure RelaxationCrown RenewalEssential Scalp RefreshCustomized Scalp TreatmentExpress Scalp Treatment
Name:*

First NameLast Name
Birth Date*

MonthDayYear
Date
Email*
example@example.com
Occupation:
Phone Number:*
Please enter a valid phone number.
How did you hear about us?*
If referred by a friend or a business, who should we Thank for sending you to us?
Emergency Contact Name:*
Emergency Contact Number:*
Please enter a valid phone number.
Medical Information:

Medical information ensures safe, customized head spa treatments by identifying allergies, health conditions, and preferences to enhance client comfort and prevent complications.
Are you taking any medications?*
If yes, please list name and use:
Are you currently pregnant?*
Any high risk factors?
Do you suffer from chronic pain?*
If yes, please explain:
Have you had your hair colored within 72 hours?
Do you suffer from any of the following?*

PsoriasisEczemaExcessive hair lossDry scalpOily scalpCovid / Thinning hairProduct / Skin build upNone of the above
Do you get Claustrophobic? *
Do you like your feet to be tucked in or sheets loose?*
Do you have any new ear piercings?
Are there any areas of your upper body you don't prefer touched?
Would you like a quiet appointment or would you like a step by step explanation of the service steps ? *
Have you had any orthopedic injuries?*
If yes, please list:
Please indicate any of the following that apply to you:*

Headaches/MigranesDiabetesJoint ReplacementHigh/Low Blood PressureNeurotherapyFibromyalgiaStrokeHeart AttackKidney DysfunctionBlood ClotsNumbnessSprains or strainsPacemakerCancerSurgical HardwareOther (If condition is not listed, please specify)
Have you had a professional body or head massage before?*
What pressure do you prefer?*

LightMediumDeep
Rate your stress level:*

High- 8-10Medium- 4-8Low- 1-3
Do you have any allergies or sensitivity to essential oils or scents?*
If yes, please explain:
What are your goals for this treatment session?
Do you currently wear hair extensions?
Please let us know the length of your hair.
Please let us know the thickness of your hair
I understand that the therapeutic session I receive is provided for the basic purpose of relaxation, and head and scalp care. I understand that some redness/irritation is possible, and I need to ask my therapist about follow-up care. If I experience any pain or discomfort during this session, I will immediately inform the therapist. I affirm that the above information is accurate and true to the best of my knowledge, and to keep the practitioner updated as to any changes in my medical profile. I understand that my scalp therapist will not be able to make any diagnoses and they will refer me to see a doctor if they see something of concern. I do hereby waive, release, and forever discharge the operation and operating practitioner of Dolce Vita Salon from any responsibility or liability related to my services.
I agree to the above statementI agree to use electronic records and signatures
Service Policy*

I agree to the above statement
Acknowledgment of Equipment Weight Limit and Accessibility

Our salon is committed to providing a safe and comfortable experience for all clients. To ensure the safety and integrity of our equipment, as well as compliance with legal and safety standards, we kindly request your acknowledgment of the following:
• The maximum weight capacity for our service bed/device is 300 pounds.
• Clients must be able to independently get onto and off of the service bed/device without assistance from salon staff, as we are unable to provide physical assistance in this regard.

By signing below, you confirm that you understand and agree to these limitations. If you have any questions or concerns, please let us know prior to your appointment so we can discuss potential accommodations to best meet your needs.

Thank you for your understanding and cooperation.
Personal Information

Your personal information is collected so we can identify clients, customize services, and facilitate communication for appointment scheduling and follow-ups, ensuring a personalized and seamless experience. If you have any concerns or questions regarding your data privacy, please visit Privacy Policy for more information. You can also contact us directly at info@dolcevitasalon-sr.com or call us at 707-538-3969.
Signature:*

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Scalp Wellness Intake Form

Medical Information: