Head Spa Client Consent

Appointment Date

First Name

Last Name

Phone

Date of Birth

In case of emergency

First Name

Last Name

Emergency contact phone number

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

If client referral, please list name so they can get reward points

Do you have any known allergies?

Yes

If yes, what?

Are you taking any medications?

Yes

If yes, what?

Are you ok with aromatherapy essential oils?

Yes

If no, please list

What is your hair texture?

Fine

Medium

Coarse

What is your scalp condition?

Normal

Oily

Dry

Sensitive

Describe any current scalp issues (e.g., itching, flaking, redness, dandruff, etc.)

Do you have any skin conditions or sensitivities?

Yes

If yes, please list

Have you had a reaction to any skincare products?

Yes

If yes, please list

Have you been diagnosed with eczema, psoriasis or rosacea?

Yes

Have you received any of these facial hair removal services in the last 7 days?

Waxing/Sugaring

Threading

Laser/Electronysis

Do you currently use:

Accutane

Retin-A

Predcribed topical cream

If prescribed topical cream, what?

Are you currently using any products that contain

AHA ( Glycolic acid, Lactic acid, Etc )

Vitamin A Derivative (retinol / retinoid )

BHA ( Salicylic acid )

Exfoliating scrubs

Have you ever received chemical peels, facial laser services of microdermabrasion?

Yes within the last month

Yes, over 3 months ago

I understand that the Head Spa treatment involves various techniques and products designed to promote scalp health, improve circulation and enhance relaxation. These may include but are not limited to:

· Scalp massage

· Application of oils, creams or other products to the scalp

· Steam therapy

· Use of specialized tools for scalp stimulation

I understand that while the Head Spa treatment is generally safe, there may be risks associated with it, including but not limited to:

· Skin irritation or allergic reactions to products

· Discomfort or pain during the treatment

· Rare incidences of adverse reactions to massage or stimulation techniques

I understand it is my responsibility to inform the staff member performing the treatment of any allergies, sensitivities or medical conditions that may affect my ability to safely undergo the treatment. I acknowledge that the treatment process has been explained to me, including any potential risks, and has answered all my questions to my satisfaction. I consent to receiving the Head Spa treatment, understanding the risks involved and release Dolce Organic Salon, Med Spa & Salt Room and it’s staff from any liability associated with the treatment.

I understand that clients with hair extensions are accepted but release Dolce Organic Salon, Med Spa & Salt Room and it’s staff from any damage that may be done to the hair extensions during the treatment. I also understand the scalp massage to be lighter than usual to protection the extensions.

By signing below, I acknowledge that I have read and understood the above Consent. As a client of Dolce Organic Salon, Med Spa & Salt Room, I hold harmless Kazar Business Ventures for any events under the care of any Dolce Organic Salon, Med Spa & Salt Room employee.

Date / Time

Signature

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