Scalp Wellness Intake Form

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Choose your experience* This field is required.
Scalp Discovery
Scalp Wellness Maintenance
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Contact information* This field is required.
Full Name (First name & Last name)
Birth Date (mm-dd-yy)
Phone number
Email address (email@domain.com)
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Welcome to Your Scalp Wellness

Discovery Session

We're so glad you're here!

Your Discovery Session is the first step in understanding what's happening beneath the surface of your scalp. Before we meet, we'd like to learn more about your health history, lifestyle, hair care routine, and the concerns that brought you to us.

The information you provide helps us prepare for your appointment so we can spend more time discussing your intake form and creating a personalized plan.

During your Discovery Session you can expect:

• A detailed consultation about your concerns

• Advanced scalp imaging using our digital scalp scope

• A review of possible contributing factors

• Personalized recommendations for home care and treatment options

• Time to ask questions and discuss your next steps

*Please note: This appointment is an educational consultation and is not intended to diagnose or treat medical conditions.
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What brings you here today?* This field is required.
Hair shedding
Hair thinning
Itchy scalp
Burning
Tender scalp
Oily scalp
Dry scalp
Flaking
Psoriasis
Build-up
Other
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When did you first notice a change to your hair or scalp?* This field is required.
Less than 3 months
3-6 months
6-12 months
More than a year
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Has the condition become....* This field is required.
Worse
Better
Same
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Was there anything that happened before it started?* This field is required.
Illness
Covid
Pregnancy
Surgery
Stress
Weight loss
Medication
Menopause
Unknown
Other
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Are you currently using GLP-1Please include the type and brandname
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Are you currently.....
Pregnant
Breastfeeding
Under a doctor's care
Taking medications
Taking supplements
Other
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Do you have any medical conditions listed below?* This field is required.
Thyroid
PCOS
Autoimmune
Diabetes
Hormone imbalance
Anemia / Low Iron
None
Alopecia Areata
Trichotillomania
Other
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Does your medical condition require any medications ,supplements or under the care of a doctor?If so, please list here
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If you have an autoimmune disorderplease list here along with any treatments, medication or supplements you are taking.
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Tell Us About Your Lifestyle* This field is required.
Low / Below Normal
Medium / Normal
High / Above Normal
Stress level
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Exercise
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Smoking
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Alcohol
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Sleep
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Diet
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Water intake
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Swimming
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Heavy sweating
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Sun exposure
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Stress level
Exercise
Smoking
Alcohol
Sleep
Diet
Water intake
Swimming
Heavy sweating
Sun exposure
Low / Below Normal
Row 0, Column 0
Medium / Normal
Row 0, Column 1
High / Above Normal
Row 0, Column 2
Low / Below Normal
Row 1, Column 0
Medium / Normal
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High / Above Normal
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Low / Below Normal
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Medium / Normal
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High / Above Normal
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Low / Below Normal
Row 3, Column 0
Medium / Normal
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High / Above Normal
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Low / Below Normal
Row 4, Column 0
Medium / Normal
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High / Above Normal
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Low / Below Normal
Row 5, Column 0
Medium / Normal
Row 5, Column 1
High / Above Normal
Row 5, Column 2
Low / Below Normal
Row 6, Column 0
Medium / Normal
Row 6, Column 1
High / Above Normal
Row 6, Column 2
Low / Below Normal
Row 7, Column 0
Medium / Normal
Row 7, Column 1
High / Above Normal
Row 7, Column 2
Low / Below Normal
Row 8, Column 0
Medium / Normal
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High / Above Normal
Row 8, Column 2
Low / Below Normal
Row 9, Column 0
Medium / Normal
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High / Above Normal
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What specific products are you using in your hair care routine?
Current Shampoo (if applicable)
Current Conditioner (if applicable)
Dry Shampoo (if applicable)
Hair Oil or Scalp Serums (if applicable)
Minoxidil (Topical % or Oral%)
Nutrafol (Yes/No)
Viviscal (Yes/NO)
Other scalp products (if applicable)
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How often are you washing your hair?* This field is required.
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When was the last time you had a blood panel done? * This field is required.Blood panels are helpful resources. If you've had one within the past 3 months, please bring it to your appointment.
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About Your Hair * This field is required.
Please Select
Please Select
☐ Fine
☐ Medium
☐ Coarse
Hair Strand Thickness (How thick does each individual strand feel?)
Please Select
Please Select
☐ Thin
☐ Average
☐ Thick
Hair Density (How much hair do you feel you have?)
Please Select
Please Select
☐ Straight
☐ Wavy (2A–2C)
☐ Curly (3A–3C)
☐ Coily (4A–4C)
Natural Hair Pattern
Please Select
Please Select
Yes
No
Is your hair currently color-treated?
Please Select
Please Select
Yes
No
Do you currently wear hair extensions?
If you wear hair extensions what type?
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Your Hair History* This field is required.(Select all that apply)
Please Select
Please Select
Yes
No
Have you chemically relaxed or permanently straightened your hair?
Please Select
Please Select
☐ Permanent color
☐ Highlights / Balayage
☐ Bleach
☐ Gloss / Toner
☐ Relaxer
☐ Perm
☐ Keratin / Smoothing Treatment
☐ At-home hair color
☐ None of the above
Which chemical services have you had in the past 3 years?
Please Select
Please Select
☐ Dry
☐ Oily
☐ Frizzy
☐ Damaged
☐ Color-treated
☐ Chemically treated
☐ Difficult to style
☐ Easily weighed down
☐ Holds styles well
☐ I'm not sure
How would you describe your hair? (Select all that apply.)
Please Select
Please Select
☐ Daily
☐ Several times a week
☐ Occasionally
☐ Rarely
☐ Never
Do you regularly use heat styling tools?
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Your Hair Baseline

One of the best ways to track progress is by knowing where you're starting. By uploading photos this helps us become familiar with your hair before your appointment and creates a visual baseline that can be referenced throughout your scalp wellness journey.

If you can, please upload clear photos of your:

Front hairline

Left temple

Right temple

Crown

Natural part line

Back of your head

Natural lighting is ideal, and there's no need to style your hair perfectly—we're simply looking for an honest representation of your hair today.

If you're unable to upload photos, don't worry. We'll capture them together during your appointment.
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PhotosPhotos are extremely helpful for us to get an idea your hair lease upload the FRONT, BACK, RIGHT TEMPLE, LEFT TEMPLE, CROWN & PART LINE of your Hair.
Drag and drop files here
Select files to upload
Cancelof
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Final Questions* This field is required.
What are your expectations from this visit?
Anything else you'd like us to know before your appointment? ?
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Welcome to Your

Scalp Wellness Maintenance

We're so glad you're here!

Whether this is your first scalp treatment or you're continuing your scalp wellness journey, today's service is designed to improve the health of your scalp while supporting stronger, healthier-looking hair over time.

Before your appointment, we'd like to learn about your current scalp concerns, recent changes, and treatment goals so we can customize today's service to meet your scalp's unique needs.

Your appointment may include:

• A brief scalp check-in with our imaging scope

• Professional scalp cleansing and exfoliation, when appropriate

• Customized scalp treatments selected for your current needs

• Steam therapy and nourishing scalp care products

• Personalized home care recommendations, when appropriate

Please note: If you're experiencing significant hair thinning, excessive shedding, persistent itching, scalp discomfort, or other ongoing scalp concerns, we may recommend scheduling a Scalp Wellness Discovery Session in our Private Scalp Lounge. This comprehensive consultation allows us to perform advanced scalp imaging and create a personalized long-term treatment plan.

This questionnaire should take approximately 3–5 minutes to complete.

*Please note: This appointment is not intended to diagnose or treat medical conditions.
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Scalp Wellness* This field is required.
I'm a new client
I have received Scalp Wellness treatment before
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Update Since Last visit* This field is required.
Any medication changes?
Please Select
Please Select
Yes
No
Are you pregnant?
Any changes in your scalp?
Any new products?
Any changes in hair shedding?
Goals for this visit.
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Health & Safety* This field is required.Pure Relaxation
Pregnant
Medical conditions
Recent surgery
Recent illness
High blood pressure
Open wounds
Other
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Do you have a preferred day and time for this appointment?* This field is required.
Yes, I have preferred day and time.
No, I have a flexible schedule.
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Scheduling* This field is required.
Preferred Day
Preferred Time
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Acknowledgement of Service

I understand that some redness/irritation is possible, and I need 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 my scalp therapist will not be able to make any diagnoses and they will refer me to see a doctor if they see something of concern. I do hereby waive, release, and forever discharge the operation and operating practitioner of Dolce Vita Salon from any responsibility or liability related to my services.

I understand that the therapeutic session I receive is provided for the basic purpose of relaxation, and head and scalp care. I understand that some redness/irritation is possible, and I need 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 my scalp therapist will not be able to make any diagnoses and they will refer me to see a doctor if they see something of concern. I do hereby waive, release, and forever discharge the operation and operating practitioner of Dolce Vita Salon from any responsibility or liability related to my services.
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Need Help Booking?* This field is required.If you're confident about the service you want, feel free to book your appointment online. However, if you're unsure what to book, we’re happy to assist! Let us know below if you would like a team member to call you to help with scheduling.
I'm already scheduled
Yes, I’d like someone to call me and assist with booking.
No, I know what to book and will schedule online. (by choosing this, you will be redirect to our online booking platform)
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Welcome to Your Scalp Wellness

Discovery Session

Welcome to Your

Scalp Wellness Maintenance