FORM: JAPANESE HEAD SPA CONSULTATION | Queen St. Hair | Colourist Of The Year Winner 2024 | Japanese Head Spa | Hair Salon in Uppingham, Rutland, LE15 9QR

First name

Last name

Phone

Email

Is this your first Japanese Head Spa treatment?

Yes

No

If you have selected any of the above please give further details:

Are you on any medication?

Yes

No

Do you have a nut allergy?

Yes

No

Are you pregnant?

Yes

No

Have you had any cancer treatment within the last 12 months?

Yes

No

Any known allergies to essential oils or product ingredients?

Yes

No

If you have selected YES to any of the above please give further details:

If you have selected any of the above please give further details:

I consent to the use of essential oils including a scalp, neck and shoulder massage as part of my treatment.

I understand that scalp massage may cause temporary discomfort or redness.

I attest that the information provided above is true and complete and therefore I give my authorisation for my treatment.

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