Japanese Herbal Scalp Treatment
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
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Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Have you ever had a scalp treatment?
Yes
No
Are you taking any medications?
Are you pregnant
Yes
No
Do you Suffer from any of the following:• Psoriasis• Eczema• Excessive hair loss• Dry scalp• Oily scalp• Covid/ Thinning hair• Product / skin build up• Migraines• None of the above
Please indicate any of the following that apply to you: *• Cancer• Headaches/Migranes• Arthritis• Diabetes• Joint Replacement• High/Low Blood Pressure• Neurotherapy• Fibromyalgia• Stroke• Heart Attack• Kidney Dysfunction• Blood Clots• Numbness• Sprains or Strains• Pacemaker• None of the above
Are there any other conditions that not listed above?
Have you had a professional body or head massage before?
Rate your stress 1 Is low 5 is high
1
2
3
4
5
Do you have any allergies or sensitivities? (Oils, herbs, foods, meds etc.))
*
Are we doing any add ons? Facial? Dermaplane? Wax?
What are your goals for this treatment session?
I understand that the therapeutic session I receive is provided for the basic purpose of relaxation, head and skin care. I understand that some redness/irritation is possible, and 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 there shall be no liability on the practitioner’s part should I fail to do so. I do hereby waive, release and forever discharge the operating practitioner of Viva La Beautyy from any and all responsibility or liability related to my services. I agree to the above statement. "I agree"
A agree to release Viva La Beautyy Photo Release FormThis form grants permission for the salon to use photographs taken during your appointment. By signing below, you acknowledge and agree to the following terms:1. **Purpose**: The salon may use your images for promotional purposes, including but not limited to social media, advertisements, and website content.2. **Usage Rights**: You relinquish any rights to the images, allowing the salon full rights to use, modify, and distribute the photographs as deemed necessary.3. **Confidentiality**: The salon will make reasonable efforts to ensure that your identity is protected in any public use of the images.4. **Consent**: By signing this form, you confirm that you are at least 18 years old or have parental consent to allow the use of your images.Please sign and date below to indicate your acceptance of these terms. I DO or I DO NOT
Signature
Required Deposit for Service
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