Scalp Facial Consultation Form

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Name *

Email *

Phone Number *

What is the purpose for booking this service? *

To address scalp issue concerns

Relaxation

To help with hair growth

All of the above

Scalp issues, please select all that apply. *

Psoriasis

Flakey Scalp

Itchy Scalp

Dry Scalp

Experiencing hair loss

Other:

Required

Is your scalp sensitive? *

Yes

IDK

If yes, please list skin irritants or allergies you have.

Do you have well water? *

Yes

IDK

Do you have extensions, locs or braids? *

Yes

Typically the service is 60-90 minutes. Do you have any neck or back issues that would make laying on the spa bed difficult or painful for an extended amount of time? *

Yes

Please list any other questions, comments or concerns: *

I consent to the use of video or photos of me or my hair to be used for the purpose of social media, website and/or other forms of marketing. *

I agree

I agree, just please do not show my face

I do not consent

How did you hear about us?

Once you have submitted this form you may request an appointment at the booking link below

https://midwest-social.square.site

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