Scalp Facial Consult Form Name * First Name Last Name Email * Phone (###) ### #### Tell us what interests you in this service. Scalp Issue Concerns Relaxation Encourage Hair Growth All of the Above Do you have any current scalp issues? Psoriasis Flaky Scalp Itchy Scalp Dry Scalp Hair Loss Is your scalp sensitive? Yes No Idk If yes, please list skin irritants or allergies you have. Do you have well water? Yes No Idk Do you have extensions, locs, or braids? Yes No 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 No Questions/Concerns 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, but do not show my face. I do not consent. How did you hear about Midwest Social? Thank you!
