New Patient Intake Form

Please fill out the following form to help us understand your physical condition.

First name

Email Address

Last name

Date of Birth

Gender:

Male

Female

Emergency Contact

Are you currently pregnant?

Yes

Emergency Contact Phone

Have you had a head spa before?

Yes

Are you okay with aromatherapy essential oils?

Yes

Do you have any allergies or sensitivites?

Yes

If you answered yes to any question, please elaborate

Do you have any known scalp conditions, skin infections, diseases, viruses, or recent injuries/surgeries?

Yes

If you answered yes to any question, please elaborate

What are your goals for your head spa session?

How did you hear about us?

Heavenly Head Spa Liability Waiver

If I experience any pain or discomfort during my head spa session, I will immediately inform my practitioner so that pressure may be adjusted to my comfort level. I further understand that head spa should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, for any mental or physical ailment of which I am aware.

Because treatment should not be performed under certain medical conditions, I affirm that I have answered all questions honestly. Failure to answer the above questions honestly results in all liability to fall on the client and not the practitioner or Heavenly Head Spa. I agree to keep Heavenly Head Spa updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. Understanding all of this, I give my consent to receive care.

Your Signature

I agree to use electronic signatue in accordance with these terms.

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Heavenly Head Spa Liability Waiver

Lateness up to 15 minutes will be deducted from your scheduled appointment time. After 15 minutes you will be considered a no-show and charged according to our cancellation policy (50% of service)

Heavenly Head Spa will send an appointment reminder prior to your scheduled service. You must reschedule or cancel your appointment at least 24 hours before your scheduled appointment time. Failure to do so will result in being charged according to our cancelation policy (50% of service)

Your Signature

I agree to use electronic signatue in accordance with these terms.

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Heavenly Head Spa Policies

Clients should arrive to appointment free of make-up and jewelry.

All retail and gift card sales are final.

All services are final once completed, no refunds will be issued.

Guests, including children, are not permitted during your appointment, with the exception of parent/guardian remaining present during head spa for ages 15 and under.

I understand that I should wait at least 2 weeks after receiving hair extensions to book a head spa, and at least 1 week before and after a chemical service of any kind.

Clients under 18 must complete parental/guardian consent waiver.

Clients under 16 must have parent/guardian present during their appointment.

Your Signature

I agree to use electronic signatue in accordance with these terms.

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I hereby grant permission to Heavenly Head Spa to use photographs or video of me taken during my head spa session on social media, website, or advertisements.

Yes, I Agree

No, I Do Not Agree

Today's Date

I declare that the info I’ve provided is accurate & complete