Consultation

Please fill out this form prior to your Head Spa treatment to help us personalize your experience and ensure your safety.

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Personal Information

Full Name

Date of Birth

Phone

Emergency Contact Name

Emergency Contact Phone

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Health Information

Are you currently in medicare care?

If Yes, please explain

Do you have any scalp conditions (dandruff, psoriasis, eczema, etc.)?

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

Please list allergies if any:

Are you currently pregnant?

Do you suffer from migraines, frequent headaches, or tension?

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Hair & Scalp History

How often do you shampoo your hair?

Have you had recent chemical treatments (color, relaxer, perm)?

Do you experience hair thinning or hair loss?

Do you have a sensitive scalp?

What are your primary concerns for today’s treatment?

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Treatment Preferences

Preferred pressure (light / medium / firm):

Do you prefer aromatherapy during your treatment?

Would you like a scalp analysis prior to treatment?

Additional requests:

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Consent

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I acknowledge that the information provided is accurate to the best of my knowledge. I release La Ritz Spa & Salon from any

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Date