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639 Queen Street East Toronto, Ontario M4M 1G4
+1 416-778-8892
Album Hair
Hair Salon Located in Leslieville Toronto
ABOUT
SERVICES
CUT
COLOUR
Balayage / Ombre Colour
Full Highlights Colour
Partial Highlights Colour
Roots to End Hair Colour
Root Colour Touch-Up
Colour Correction
STYLE
SCALP MASSAGE THERAPY
BRIDAL
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Queen East Team
Queen West Team
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Queen East Location
Queen West Location
About
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Style
Scalp Massage Therapy
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Queen East Location
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Scalp Massage Therapy Form
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Scalp Massage Therapy Form
Scalp Massage Therapy Health Questionnaire Form (required)
Full name : (required)
Email : (required)
1. Cardiovascular conditions (Please describe):
2. Pulmonary conditions (Please describe):
3. Neurological conditions (Please describe):
4. Musculoskeletal conditions (Please describe):
5. Infectious conditions (Please describe):
6. Psychological conditions (Please describe):
7. Sensory loss (Please describe):
8. Gynecological conditions (Please describe):
9. Allergies or skin conditions (Please describe):
10. Medical implants (Please describe):
11. Any other conditions or symptoms that have not been mentioned above? If so (Please describe):
12. Have you had any major accidents, injuries, or surgeries? If so (Please describe):
13. Are you currently taking any medication? If so (Please describe):
TODAY’S TREATMENT INTAKE(required)
1. What is your reason for seeking treatment today?
2. Do you have any treatment goals?
3. Have you received massage therapy before?
SCALP HISTORY
Previously Chemical?
Yes
No
Current Hair Loss?
Yes
No
Dry scalp and/or dandruff?
Yes
No
HOME REGIME
Hair care products :
Frequency of washing :
Frequency of thermal styling :
Other
Percentage (%) of Gray:
Hair Type: (Please check all that apply)
Coarse
Medium
Fine
Hair Density: (Please check all that apply)
Thick
Average
Fine
Additional Comments:
INFORMED CONSENT FOR TREATMENT
I,
, acknowledge that the massage therapy provided to me at Album Hair is intended to promote
relaxation, reduce pain caused by muscle tension, improve circulation, and provide a positive
experience of touch.
The general benefits of massage, possible contraindications, and the treatment procedure has
been explained to me. Contraindications for massage include, but are not limited to: fever,
uncontrolled diabetes or hypertension, acute local inflammation, infectious skin rashes, and
suspected DVTs/phlebitis.
I acknowledge that massage therapy is not a substitute for medical treatment or medications
and that it is recommended I concurrently work with my primary physician for any medical
condition for which I was diagnosed.
I take responsibility for alerting my therapist to any physical, mental or emotional changes that
occur with my health. I acknowledge that the therapist’s knowledge about my health background
is very important before I receive a massage and acknowledge that my records will be kept
confidential. I am aware that the massage therapist does not diagnose illness or disease, and
does not prescribe medications.
I have informed the massage therapist of all known physical conditions, medical conditions,
medications and have authorized my caregivers to provide information concerning my physical
and medical condition. I acknowledge that the Massage Therapist reserves the right to postpone
my appointment if a physician’s approval is needed before receiving massage therapy.
Client's-Name
Client's Signature
Date
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