Crown Revival Consultation Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthday*

Date

Email Address*

example@example.com

Phone Number*

Please enter a valid phone number.

Do you allow text messages to this phone:*

YesNo

Instagram Handle:*

What is your profession?*

Why are you booking this service?*

Rejuvenation/RelaxationDetermine a scalp care plan to help with scalp issues/concernsTo help with hair growthAll of the above

What issues/concerns are you struggling with, If Any?*

When did you first notice this? How long have you been experiencing it?

Are you on well water?*

YesUnsureNo

Do you have a sensitive scalp?*

YesNoUnsure

Please list all of the products to the best of your ability, that you currently use and have been using for the last 6 months, and if you have switched to anything new.*

Do candles or essential oils bother you? If so please explain:*

Do you have any neck/spinal or back issues?*

YesNo

Any recent surgeries that might make certain positions uncomfortable?*

Are you currently taking any medication? - OR stopped? If so please elaborate?*

Do you have any medical conditions I should be aware of?*

To ensure I can provide the desired therapeutic effects without causing harm, do any of the below apply to you:*

Sensitive Areas around eyes, temples, or throatExisting Medical Conditions (i.e. sound-related PTSD, neurological disorders)Broken Skin or WoundsBone Weakness (i.e. Osteoporosis, Osteopenia, Fractures etc)Pace MakerMetal/Replacement PartsHearing AidsNone of the above apply

If you check-marked any of the above, please provide details below:

Has your blood work ever shown deficiencies? If so please explain:*

Have you seen a dermatologist/scalp specialist?*

YesNo

If yes, what did they say?

How is your current stress level?*

How would you rate your current health/fitness?*

ExcellentGoodNeeds some workPoor

Have you had lice in the past 6 months? Are you concerned you might have lice now?*

YesNoPossibly

How often do you wash your hair?*

EverydayEvery other day2-3 x per weekOnce per week or less

Do you blowdry your hair?*

YesNoSometimes

Do you go to bed with wet hair?*

YesNoSometimes

Are you pregnant or nursing?*

YesNo

Please list any scalp care tools or products that you are currently using:*

Do you have any sensitivities or allergies to products or ingredients? If so, please elaborate:*

Has your scalp been sun burnt within the last three weeks?*

YesNo

Are you currently wearing hair extensions? If so, please share what kind:*

All scalp facial sessions include a complimentary blow-dry finish (no hot tools), so you can leave feeling fresh and comfortable. If you’d like to add styling — such as soft waves or smoothing with a flat iron — you may add a Styling Add-On for $35

Yes, that would be amazing please add this onNo, feeling fresh is fine. The complimentary blow-dry finish is perfect

How did you hear about our headspa service? Did someone refer you?*

I acknowledge that the techniques used during this treatment are proprietary to Kristin Schutz at The Chair and agree not to copy, record, or disclose them for personal or professional use.*

No problem at all! I AgreeI DisagreeI am not a Salon Professional

I authorize Kristin Schutz at The Chair to take photographs/videos of my treatment results for documentation and marketing purposes (e.g., social media, website). I understand I can withdraw this consent at any time in writing. No identifying information will be shared unless explicitly agreed upon:*

Yes, I give permissionNo, Please keep all media private

Cancellation & Rescheduling Policy

To honor the care and focus dedicated to each session, please be aware of the following policy: Any changes or cancellations require at least 48 hours notice via text or email. Cancellations made within 24 hours or missed appointments will incur a charge of 100% of the full service price of $250.

A 50% NON REFUNDABLE DEPOSIT will be charged to your card to reserve this service.

By submitting your credit card information at the time of booking this service you confirm your understanding and acceptance of this policy.

These guidelines ensure respect for both your time and mine, and helping maintain a calm and intentional spa space for everyone. Thank you for supporting thoughtful small business practices.

Do you agree to the cancellation and rescheduling policy?*

Yes, I Agree

Do you agree to the non refundable deposit policy?*

Yes, I Agree

Data Privacy Acknowledgment (CCPA Compliant)

I understand that my personal and health information is being collected solely for use by Kristin Schutz with The Chair to provide wellness services. My information will never be sold or shared. I may request access to or deletion of my information at any time*

I acknowledge and consent to the collection of my information in accordance with California privacy laws