Scalp Massage Intake Form

Today's Date

First Name

Last Name

Date of Birth

Phone Number

Email Address

Emergency Contact and Phone Number

Medical & Lifestyle Information

Do you have any allergies (including topical products or essential oils)?

Yes No

If yes, please list

Is fragrance okay to use during your treatment?

Yes No Unsure / Depends on the product

Have you had a head spa or scalp treatment before?

Yes No

If yes, when and where?

Are you currently under the care of a dermatologist for your scalp or hair?

Yes No

If yes, please specify

Are you taking any medications that may affect your hair or scalp?

Yes No

If yes, please list

Treatment Goals

What would you like to achieve from this treatment?

Other

Scalp & Hair Profile

Do you have any scalp concerns? (Check all that apply)

Other

Are there specific areas of concern on your scalp?

Crown Nape / Neckline Hairline / Edges Temples

Part Line Behind the ears Overall / Diffuse Not sure

What hair/scalp products do you currently use? (Check all that apply)

Other

What is your typical shower routine?

Daily Every 2–3 days Weekly

Other

Describe your usual hair care routine (e.g., detangling, drying, styling)

Hair Characteristics

How long is your hair?

Short Medium Long Very Long

What type of hair do you have? (Check all that apply) If you're unsure about your hair type, let us know and we'll help you assess it during your visit.

Medium Thick High density (lots of hair strands) Low density (fewer strands)

Does your hair tangle easily?

Yes No Sometimes

Are you planning on blow drying your hair after treatment?

Yes No Unsure

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