Headspa Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Gender

HOW DID YOU HEAR ABOUT HAIR VIRTUE?

SCALP CONCERNS AND GOALS

HAVE YOU BEEN TO A DERMATOLIGST WITH SCALP CONCERNS OR HAIR LOSS? EXPLAIN THE DIAGNOSIS:

SCALP CONDITIONS

HAIR LOSS CONCERNS

MEDICAL INFORMATION

ANY OTHER MEDICAL INFORMATION PLEASE EXPLAIN:

ALLERGIES TO SPECIFIC PRODUCTS OR INGREDIENTS:

RECENT SURGERIES OR TREATMENTS:

OTHER MEDICAL CONCERNS:

HAVE YOU HAD A PROFESSIONAL HEAD OR BODY MASSAGE

WHAT PRESSURE DO YOU LIKE?

CONSENT AND AGREEMENT

I UNDERSTAND THAT THE HEADSPA TREATMENT IS DESIGNED TO SUPPORT A HEALTHY SCALP ENVIRONMENT THROUGH CLEANSING, EXFOLIATION, MASSAGE, AND PROFESSIONAL SCALP CARE. WHILE THESE SERVICES MAY HELP IMPROVE THE APPEARANCE AND OVERALL HEALTH OF THE SCALP AND HAIR, INDIVIDUAL RESULTS MAY VARY.

I ACKNOWLEDGE THAT HAIR VIRTUE SALON, LLC DOES NOT GUARANTEE HAIR GROWTH OR PROMISE THE RESOLUTION OF ANY SCALP CONDITION. THIS SERVICE IS NOT INTENDED TO TREAT, CURE, OR DIAGNOSE ANY MEDICAL CONDITION AND SHOULD NOT BE CONSIDERED A SUBSTITUTE FOR MEDICAL ADVICE OR TREATMENT FROM A LICENSED HEALTHCARE PROVIDER.

I ACKNOWLEDGE THAT IF ANY REDNESS, IRRITATION, PAIN, OR DISCOMFORT OCCUR DURING OR AFTER MY TREATMENT THAT I WILL INFORM MY STYLIST.

I AFFIRM THE INFORMATION I HAVE PROVIDED IS ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I AGREE TO INFORM THE STYLIST OF ANY CHANGES TO MY MEDICAL HISTORY. I UNDERSTAND THAT THE STYLIST IS NOT LIABLE FOR ANY ADVERSE REACTION THAT MAY RESULT FROM MY FAILURE TO DISCLOSE RELEVANT MEDICAL INFORMATION.

IF YOU AGREE, PLEASE SIGN:

Signature

Date

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