New Client Intake Form

Full Name

First NameLast Name

Email Address

example@example.com

Phone Number

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

Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Please share any relevant background information or notes

What would you most like help with during your Head Spa experience?

If you are experiencing a specific hair or scalp concern, when did you first notice it? Is there anything you believe may have contributed to it?

How would you describe your scalp?

Tell me a little about your current hair + scalp routine.

How would you describe your natural hair texture?

Do you currently have extensions, box braids, protective styles, locs, or another installation/style that may limit access to your scalp?

If yes, please describe your current style or installation.

Do you have any known allergies or sensitivities, including essential oils, botanical ingredients, fragrances, haircare ingredients, or topical products? Please list anything you know you prefer to avoid.

Are you currently pregnant, recently postpartum, or nursing?

Do you have any injuries, conditions, recent procedures/surgeries, or physical limitations involving your neck, shoulders, back, spine, scalp, or skin that I should be aware of before performing your service? Please explain.

Are you currently under the care of a dermatologist or medical provider for a hair or scalp concern? If yes, what guidance or diagnosis, if any, have you been given that would be helpful for me to know?

Do you currently have any open wounds, sores, significant irritation/inflammation, active rash, or a recent scalp sunburn?

Do you currently have, or have you recently completed treatment for, head lice, scabies, ringworm, impetigo, or another contagious skin/scalp condition?

If recently treated, please provide the condition and approximate treatment completion date.

Have you had a Head Spa, scalp facial, or similar treatment before?

If yes, was there anything you especially loved, disliked, or would prefer I do differently?

How would you describe your current stress level?

Is there anything else you'd like me to know before your appointment?

Head Spa services are cosmetic and wellness services and are not intended to diagnose, treat, or cure medical conditions. I agree to disclose any relevant allergies, sensitivities, contagious conditions, injuries, or health considerations that could affect my service. I understand that my service may need to be modified, postponed, or declined if a condition is present that makes treatment inappropriate.

Signature

From time to time, I may capture photos or short video clips during salon services to showcase my work, educate others, and create content for my website, social media, marketing, or other business-related platforms.

Your comfort and privacy are important. Participation is completely optional, and your choice will not affect your service or experience in any way.

I DO NOT CONSENT — I do not give permission for photos or videos of me or my service to be captured for content or marketing purposes.

I CONSENT — I give permission for photos and/or videos to be taken during my service and understand that my face may be visible. I consent to this content being used for Balanced Beauty's social media, website, educational, promotional, and marketing purposes.

I CONSENT — PLEASE DO NOT SHOW MY FACE — I give permission for photos and/or videos to be taken during my service as long as my face is not visible or identifiable in the final content. Content may include my hair, scalp, back or side of my head, hands, or portions of the service that do not reveal my face.

I CONSENT — AN EYE MASK MAY BE USED FOR PRIVACY — I give permission for photos and/or videos to be taken during my service, including angles where my face may otherwise be visible, provided that an eye mask is worn to provide facial privacy. I am comfortable with the remainder of my face being visible while wearing the eye mask.

Please select the option that best reflects your preference.

Please verify that you are human

New Client Intake Form

Head Spa New Client Intake

Health + Safety

Your Experience

Photo & Video Content Consent