Hair & Scalp Rejuvenation Report Form

Thebox:V'Jinga Holistic Spa

The Herbal Head Spa Consultation
Patient Name

First NameLast Name
Date of birth

MonthDayYear
Date
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Consultation

MonthDayYear
Date
Consultant's Name

First NameLast Name
Any Known Allergies or Sensitivities to Essential Oils or Ingredients? (Include Products and Plants)

YesNo
If yes, please specify
Are you currently taking any medications?

YesNo
If yes, please list the medications
Do you have any chronic health conditions?

YesNo
If yes, please specify
Hair Type

StraightWavyCurlyCoily
Hair Texture

FineMediumCoarse
Scalp Condition

NormalExcessive OilyDry/ FlakingSensitiveCombination (Oil scalp, dry ends)
Do you experience any tenderness or discomfort when touching your scalp?

YesNo
Describe any current hair issues (e.g., thinning, breakage, dandruff)
Please Check all that Apply:

Hair Loss/ThinningDandruff/Scalp IrritationHair Damage/BreakageScalp Tension/PainOther:________________________________________________________________________________
Describe any current scalp issues (e.g., itching, flaking, redness)
How often do you wash your hair?

DailyEvery other dayWeeklyOther
How would you describe your stress levels regularly?

LowModerateHighOther
Do you work or live in an environment with significant pollution or harsh weather conditions?

YesNo
What type of hair care products do you regularly use?

Sulfate-freeMoisturizingClarifyingOther:_______________________________________
What type of shampoo and conditioner do you use?
Do you use any hair treatments or styling products? (Coloring, Perming, etc.)

YesNo
If yes, please list the products
Do you use heat styling tools?

YesNo
If yes, how often?
Do you follow any specific diet or have any dietary restrictions?

YesNo
If yes, please specify
GOALS: Check all that Apply

Improve hair growth/lengthReduce scalp irritation/dandruffRepair hair Damage/BreakageRelieve Scalp tension/PainImprove overall hair healthOther:________________________________________________________________________
Any other diagnostic tests performed

YesNo
If yes, please specify
I grant permission Thebox:V'Jinga Holistic Spa to take photographs, videos, or other
media for use in marketing, advertising, social media, website, newsletters, magazines, recruiting brochures, emails, books, and general publications.
I hereby waive any right to inspect or approve the finished photographs or
electronic matter that may be used in conjunction with them now or in the future,
whether that use is known to me or unknown, and I waive any right to royalties or
other compensation arising from or related to the use of the image.

I am at least 18 years of age and am competent to contract in my own
name. I have read this release before signing below, and fully understand the
contents, meaning, and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
Initial

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Patient Consent and Signature:

I have discussed and understood the assessment and treatment plan provided by my consultant. I consent to the recommended treatments and agree to follow the advised hair care routine.

I have voluntarily elected to undergo this treatment and/or procedure after the nature and purpose of this treatment was explained to me, along with the risks and hazards involved, by Thebox:V'Jinga Holistic Spa.
Although it is impossible to list every potential risk and complication, I have been informed of the possible benefits, risks, and complications of the procedure I am receiving today. I also recognize that there are no guaranteed results and that independent results are dependent upon age, skin condition, lifestyle, and other factors. I understand that I may need more treatments at an additional cost to achieve maximum results.
I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will contact my head spa specialist immediately.
I have also given an accurate and truthful account of my medical history including all known allergies or prescriptions drug products I am currently using both via ingestion and topically.
I have read and fully understand this agreement and all the information detailed above. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree not to hold Thebox:V'Jinga Holistic Spa responsible or liable for any of my medical conditions that were present but not disclosed at the time of this procedure which may be affected by the treatment performed today.
Patient's Signature and Date

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Visual Assessment of Hair: (To be Completed by Head Spa Specialist Only)
Visual Assessment of Scalp (To be Completed by the Head Spa Specialist)
Recommended Hair Treatments (To be Completed by the Head Spa Specialist)
Recommended Scalp Treatments (To Be completed by the Head Spa Specialist)
Microscopic Analysis Results (if applicable) (To Be Completed by the Head Spa Specialist)
Product Recommendations (To be Completed by the Head Spa Specialist)
Lifestyle and Hair Care Routine Recommendations (To be Completed by the Head Spa Specialist)
Next Follow-up Appointment Date

MonthDayYear
Date
AFTERCARE:
- Use recommened shampoo and conditioner.
- Avoid heat styling and chemical treatments for a few days.
- Include recommended tea and hair oils at home daily.
- Follow up with scalp massage and hair treatment in 2-3 weeks to maintain progress.
Should be Empty:

Thebox:V'Jinga Holistic Spa