Integrative Hair Therapy
Please fill out this form as best you can so we can provide you with the most relevant service.
Privacy Statement: When completing the consultation form Beulah Tempora- Therapy Boutique will request details such as contact details, address, GP information and general health for processing. I have read understand the statement.
First Name
Last Name
Date of Birth
Address
Email
Phone Number
Doctors name
GP Address
Why are you interested in our service?
How did you hear about us?
Contraindications
Are you pregnant?
Do you have diabetes?
Epilepsy
Serious Allergies
Blood pressure disorders
Skin in sections
Heart conditions
Fever
Infectious diseases
Any other conditions not specified
Can you provide more details for any that have been checked?
Scalp health
dry
normal
oily
other scalp issues
Can you provide more detail?
How would you describe the current condition of your hair?
healthy
slightly damaged
severely damaged
Can you provide more details?
Shampoo frequency
. daily
weekly
bi-weekly
as needed
How would you describe the density of your hair?
fine
medium
thick
super thick
Condition Frequency
daily
weekly
bi-weekly
. as needed
Are you currently taking any medication that has side effects that can cause hair thinning and/or hair loss?
yes
no
If so, which one(s)?
Do you have any other problematic issues? a. breaking b. shedding c. flaking d. itching e. none
Do you have now, or have had in the past, any problems with hair loss?
Select an option
yes
no
Do you wear hair extensions (weaves, kinky twists, braids, etc.)? If so, how often?
What are your long-term hair goals? (1-2 years or more) a. more length b. healthier hair c. More moisture
Is there anything you need to improve in your current method of hair care? a. daily regimen b. hair products c. eating habits d. supplements
Please describe what you want your hair to say about you (e.g. vibrant, sassy, elegant, etc.)
My hair concerns:
Thinning
Dandruff
Brittle hair
Thick hair
Itchy Scalp
Grey Hair
Dry Hair
limp
Dull hair
Breaking
Chemically Damaged
dyed hair
Informed consent and GDPR- Please read and sign.
GDPR May 2018: The data collected on this form will be used for the sole purpose of clinical massage and will not be disclosed to any external sources. For insurance purposes, these records shall be kept for at least 7 years following last session.
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Do you agree that I may contact you by post, text, and email and other forms of social media to inform you of any special offers?
Do you agree to receive my newsletter by email?
Do you agree that I may text you to remind you of when your next appointment may be?
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