Mad Head Spa Client Consent & Acknowledgment Form

You will recieve this form before your treatment, read it and prepare for it:

Please read and complete this form prior to your treatment. Your safety and comfort are our top priority.

To ensure the best experience, we ask that you confirm the following information.

Client Information
Name: _____________________________________________
Date of Birth: _______________________________________
Phone Number: ______________________________________
Email: _____________________________________________

Health Confirmation
Please check each box to confirm that you do not suffer from the following medical conditions:
[ ] Active Scalp Infections - I do not have any active scalp infections (e.g., ringworm or bacterial
infections) that could pose a risk during treatment.
[ ] Open Wounds or Recent Scalp Surgery - I do not have any open wounds, cuts, or recent scalp
surgeries, including hair transplants, that require additional healing time.
[ ] Uncontrolled High Blood Pressure or Heart Conditions - I do not have uncontrolled high blood
pressure or heart conditions that could affect my ability to safely receive this treatment.
[ ] Autoimmune Conditions Affecting the Skin - I do not have severe autoimmune conditions, such as
lupus, that could cause heightened sensitivity or inflammation.
[ ] Blood Disorders or Anticoagulant Use - I do not have a blood clotting disorder, nor am I currently
taking anticoagulant medications (blood thinners).
[ ] Severe Skin Conditions (Psoriasis, Eczema, Dermatitis) - I do not have severe scalp conditions
that could cause irritation or discomfort during treatment.
[ ] Migraines Triggered by Pressure or Essential Oils - I do not suffer from migraines triggered by pressure points or certain scents.

Client Acknowledgment
By signing below, I confirm that:

- I have reviewed the above conditions and truthfully disclosed my health information.
- I understand that Mad Head Spa treatments involve various scalp techniques, including massage,
essential oils, and other therapeutic elements.
- I acknowledge that withholding medical information may increase my risk during treatment.
- I will notify Mad Head Spa of any relevant changes to my health prior to future appointments.
Client Signature: ___________________________________
Date: _____________________________________________

Thank you for taking the time to complete this form. If you have any questions or concerns, please speak with one of our team members.