Crown Cleansing Consultation Form
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Which service are you booking for?
Transformative Color
Luxury Extensions
Crown Cleansing
Soma Flow Journey
Why are you booking this service?
*
Rejuvenation / Relaxation
Determine a scalp care plan to help with scalp issues/ concerns
To help with hair growth
All of the above
What issues/ concerns are you struggling with?
When did you first notice this? How long have you been experiencing it?
Does your home utilize well water?
*
Yes
Unsure
No
Do you have a sensitive scalp?
*
Yes
No
Unsure
Please list all products you currently use and have been using for the last 6 months
*
Please list any fragrances you dislike/are sensitive to
Do you have any neck/spinal or back pain or surgeries that could make certain positions uncomfortable?
*
Yes
No
Are you currently taking any medications? - OR stopped? If so please elaborate
*
Do you have any medical conditions I should be aware of?
Has your blood work ever shown deficiencies? If so please explain
Have you seen a dermatologist/ scalp specialist?
Yes
No
If yes, what did they say?
How is your current stress level?
How would you rate your general health/ fitness ?
Excellent
Good
Needs some work
Poor
How often do you wash your hair?
*
Every day
Every other day
2-3 X per week
Once per week or less
Do you blowdry?
*
Yes
No
Do you go to bed with wet hair?
*
Yes
No
Are you pregnant/ nursing?
Yes
No
Please list any scalp care’s products or tools you are currently using :
Do you have any sensitivities or allergies to product ingredients? If so please elaborate.
*
Do you wish to add additional services to your experience?
CBD menthol neck massage (+20)
CBD hand and forearm massage (+35)
CBD gummy (+5)
I give consent to the use of photos or videos of myself and my hair being used on social media and other forms of marketing.
*
I Agree
I Agree If my face is not shown
I Disagree
Cancellation policy: I Understand that I am required to give a minimum of 72 hours notice of cancellation/ rescheduling otherwise I will pay a cancellation/ rescheduling fee of 50% of the price of services reserved due on the day of my original appointment date. I understand if I no show, no call, I will pay for 100% of the services reserved and will not be booked again until payment is received.
*
Submit
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