C O N S E N T F O R M
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Email Address
*
example@example.com
Phone Number
*
Format: 00000 000000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Phone Number
Format: 00000 000000.
TREATMENT GOALS
PRIMARY REASON FOR VISIT - check all that apply
*
Relaxation
Scalp Health
Stress Relief
Hair Care
Other
Main Concern or Focus Areas:
*
HAIR & SCALP HISTORY
CURRENT HAIR CARE ROUTINE
What products are you using on your hair?
*
Scalp Condition - check all that apply
*
Normal
Dry
Oily
Sensitive
Itchy
Flaky
Other
Previous Treatments in the Last 6 Months
*
Hair Colouring
Perming
Scalp Treatment
Other
HEALTH HISTORY
CURRENT HAIR CARE ROUTINE
Do you have any allergies?
*
Yes
No
If Yes - please specify
Are you currently experiencing any of the following:
*
Skin Conditions (eg. eczema / psoriasis)
Migraines or Frequent Headaches
Neck Pain or Sensitivity
Sinus Issues
Other
Current Medications (if relevant to scalp / hair health) :
LIFESTYLE & WELLNESS
Dietary Information:
*
Balanced
High in Protein
Vegetarian / Vegan
Other
Stress Levels
*
Low
Moderate
High
Sleep Quality:
*
Good
Average
Poor
TREATMENT PREFERENCES
Aromatherapy Scent Preferences - if using essential oils instead of already scented products)
*
Lavendar or Cherry Blosson (Relaxing)
Peppermint (Refreshing)
Citrus (Energizing)
No Preference
Other
Massage Pressure Preference:
*
Light
Medium
Firm
Sound / Music Preference:
*
Relaxing Music
Nature Sounds
Silence
No Preference
PHOTO CONSENT
I give permission for photographs or videos taken during my session to be used by Elements Retreat for marketing purposes, including on social media, the website, and promotional materials.
*
Yes, I give concent.
No, I do not concent
CONSENT & WAIVER
I understand that this treatment may involve essential oils, scalp stimulation, and massage.
*
I agree with the above statement.
Full Name
*
First Name
Last Name
Date Signed
-
Day
-
Month
Year
Date
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