To be filled in before the first session · kept confidential
| Full name | |
|---|---|
| Phone | |
| Date of birth | |
| How did you hear about us? |
| Do you currently have… | Yes | No |
|---|---|---|
| a wound, irritation or infection on your scalp? | ||
| a flare-up of eczema, psoriasis or dermatitis? | ||
| had surgery on your head, face or neck (including a transplant) in the last few months? | ||
| neck or back problems, or dizziness? | ||
| high blood pressure or a heart condition? | ||
| a current pregnancy? | ||
| frequent migraines? | ||
| allergies (fragrances, essential oils, nuts, latex)? | ||
| had colouring, bleaching or straightening this week? | ||
| contact lenses in today? |
Details:
I confirm that the information above is accurate and undertake to report any changes. I understand that head spa is a wellness treatment with no medical purpose and does not replace medical advice.
My data is kept by the salon solely to monitor my treatments, for 3 years after my last visit. I can ask to access, correct or delete it.
| Date | |
|---|---|
| Signature |
Free template provided by HeadSpaContact · adapt it to your business. This document is not legal advice.