head spa intake form template

Scalp Treatment and Wellness Intake Form

Instructions for Use

• Print this form and have the client complete all sections in ink prior to the commencement of any scalp treatment services.
• Review the medical history section with the client to identify any contraindications that may require a physician's clearance.
• Maintain the signed document in a secure, confidential client file in accordance with local privacy regulations.

Parties and Definitions

This Intake Form is between [Company Name] ("Service Provider") and the undersigned individual ("Client").

Client Information: Full Name: [] Date of Birth: [] Phone: [] Email: []

Operative Terms and Conditions

1. Medical Disclosure: Client represents that they have disclosed all known medical conditions, including but not limited to: high blood pressure, heart conditions, pregnancy, recent surgeries, skin allergies, scalp infections, or open wounds.
2. Assumption of Risk: Client acknowledges that scalp treatments involve the use of specialized tools, essential oils, and topical products. Client assumes all risks associated with sensitivity, allergic reactions, or adverse skin responses.
3. Product Sensitivity: Client agrees to notify the Service Provider immediately if they experience any discomfort, itching, or burning during the treatment. A patch test is available upon request for any products used.
4. Service Limitations: Scalp treatments are for cosmetic and relaxation purposes only and are not a substitute for medical diagnosis or treatment of dermatological conditions.
5. Cancellations: Client agrees to provide at least [] hours' notice for cancellations. Failure to do so may result in a fee of [].
6. Privacy: Service Provider agrees to maintain the confidentiality of all personal and medical information provided herein, subject to legal requirements.

Medical History Questionnaire

Do you currently have or have you had any of the following? (Check all that apply)

• Scalp Psoriasis or Eczema
• Recent Scalp Surgery/Injury
• Contagious Scalp Conditions (e.g., Lice, Ringworm)
• Allergies to Essential Oils or Fragrances
• Pregnancy (Trimester: [__________])
• High or Low Blood Pressure

Signature and Acknowledgment

By signing below, the Client confirms that the information provided is accurate and complete, and agrees to the terms and conditions outlined above.

Signature: __________ Printed Name: [] Date: []

Legal Disclaimer: This document is a general framework intended for informational purposes only and does not constitute legal advice. Laws regarding health disclosures and service liability vary by jurisdiction. Please consult with qualified legal counsel to ensure this template complies with your local, state, and provincial regulations.