Scalp Massage Intake Form

Today's Date

First Name

Last Name

Have you received a scalp treatment before?

Yes No

What would you like to achieve from you scalp treatment today?

Do you take anything for hair loss? If yes, please list:

How often do you dye your hair?

Please list any fragrance sensitivities

Do you have any allergies or hypersensitivities? (oils, lotions, nuts, fruits, skin, etc.) If yes, please list:

Are you currently under a dermatologists care for scalp concerns? If yes, for what?

Are you taking any medications / supplements? If yes, please list:

Please mark any of the following products you use.

Health Information (Check all that apply)

Any current infectious or contagious conditions? (e.g. HIV, TB, fungal infections, shingles, warts, etc.) If yes, please list:

Consent to Treatment

By checking this box and entering my name below in the signature field, I acknowledge and understand that participating in head spa treatments, including but not limited to scalp massages, hair treatments, and other related services, carries inherent risks such as skin irritation, allergic reactions, or discomfort. I hereby release and hold harmless Circle of Wellness, its employees, and affiliates from any and all liability for injuries, damages, or adverse reactions that may occur during or after my treatment. I confirm that I have provided accurate information regarding my health, including any scalp conditions, allergies, or other relevant medical history. I voluntarily consent to undergo the treatment and agree to assume full responsibility for my well-being during the session.

Patient Name (signature)

Consent to Treatment of a Minor

Consent to Treatment of a Minor (under the age of 18): By clicking this box and entering my name below I hereby authorize Circle of Wellness to provide therapy to my child or dependent as deemed necessary.

Guardian Name

Scalp Massage Intake Form – Rockford, IL