Scalp Massage Intake Form - Rockford, IL

If you are a new patient and do not currently have an appointment scheduled, please call 779-423-1700 to schedule before filling out this form.

All new patients must complete the following intake form and Body Scan Tool Consultation Request form prior to their appointment.  Link to the Body Scan tool form can be found on the Patient Forms page.  

Medical & Lifestyle Information

Treatment Goals

Scalp & Hair Profile

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

Are there specific areas of concern on your scalp?

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

Hair Characteristics

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.

Consultation Request

Complete the Body Scan Tool
questionnaire.