Fairfield Spa
Consultation Form
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Consultation Form
Appointment Information
Service
Appointment Date
*
Appointment Time
*
Name
*
Date of Birth
Gender
Female
Male
Other
Telephone Number
*
Email
*
Address
Do You Suffer From Any Hair/Scalp Issues?
Hairloss
Dandruff
Dry Scalp
Oily Scalp
Itchy Scalp
Thinning Hair
Other
Has your Hair been Colored in Last 48 Hours
Yes
No
Do You Have Any Hair Product Allergies
Yes
No
Do you have Hair Extensions?
Yes
Please contact us ASAP as we cannot perform the Headspa if you have hair extensions.
No
What is Your Skin Type?
Normal
Dry
Oily
Combination
Sensitive
Do You Have Any Skin Conditions?
Eczema
Psoriasis
Acne
Rosacea
Dermatitis
None
Other
Have You Had Any Recent Skin Treatments? (e.g., chemical peels, laser, microneedling)
Yes
No
Do You Have Any Skin Allergies or Sensitivities?
Yes
No
Have You Had Significant Sun Exposure Recently?
Yes
Please note: Recent sun exposure may affect the treatment. Our therapist will assess your skin.
No
What Skincare Products Do You Currently Use? (Optional)
Are you Pregnant?
Yes
Please contact us ASAP as we cannot perform this treatment if you are pregnant.
No
Are you Currently Taking Any Medication?
Yes
No
Do You Have Any Known Allergies?
Yes
No
Do You Have Any Health Conditions?
Yes
No
Do You Have Any Neck/Back Problems?
Yes
No
Additional Information
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.
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