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ABOUT
SERVICES
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ABOUT
SERVICES
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FAQ
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FAQ
Head Spa consultation form
Name
Date of Birth
Gender
Female
Male
Other
Telephone Number
Email
Address
Have you experienced any of the following hair or scalp issues?
Hairloss
Dandruff
Dry Scalp
Oily Scalp
Itchy Scalp
Thinning Hair
Other (Please specify below)
Have you coloured your hair in the last 48 hours
Yes
No
Do you have any known hair product allergies?
Yes (Please specify below)
No
Do you currently have hair extensions?
Yes
No
Are you currently pregnant?
No
Yes - Please contact us ASAP as we cannot perform the Headspa if Pregnant.
Are you currently taking any medication?
Yes (Please specify below)
No
Do you have any known allergies?
Yes (Please specify below)
No
Do you have any health conditions?
Yes (Please specify below)
No
Do you have any current neck or back problems?
Yes
No
Please provide any additional information that you feel we may need to know.
Consent
I hereby consent to the treatment provided by Fairfield Spa. I understand that the treatment is not a substitute for medical treatment and that no specific medical results can be guaranteed.
Send
