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ZEN HEAD CLIENT INTAKE AND CONSENT FORM

Please read the following carefully and then sign at the end. You will receive a copy of this intake/consent form via email, and the sender will be BODY + SOUL LLC. Thank you!

I am over the age of 18 and give my permission to Zen Head to perform a head spa treatment. I understand that this treatment is not a substitute for traditional medical treatment or medications, and that it is not a medical procedure to cure eczema, psoriasis, or any skin disease.

I understand that the service provider does not diagnose illnesses or injuries, nor does the service provider prescribe medications. I understand that this treatment is for relaxation only. 

I acknowledge that if I have any medical conditions, pregnancy, allergies, medications (oral or topical) that may be affected by the treatment or services requested, I have the opportunity to discuss such conditions with the service provider. I also have clearance from my physician to receive this treatment. 

I understand that a head spa treatment cannot be performed on clients with extensions, braids, or styles that obstruct access to the scalp, or on clients with open wounds, sores, or severely inflamed scalp disorders. My service provider may determine during analysis that a head spa treatment cannot be performed. I also understand that I should wait at least 1 week before and after a chemical service of any kind. 

I understand that the risks associated with this treatment include, but are not limited to:

  • Superficial bruising
  • Short-term muscle soreness
  • Exacerbation of undiscovered injury

I therefore release the company and the individual service provider from all liability concerning these injuries that may occur during the massage session. 

The company and the service provider are not responsible for any allergic reaction I experience. 

I understand the importance of informing my service provider of all medical conditions and medications I am taking, and I will let the service provider know about any changes to these. I understand that there may be additional risks based on my physical condition. 

I understand that it is my responsibility to inform my service provider of any discomfort I may feel during the session so he/she may adjust accordingly. 

I understand that I or the service provider may terminate the session at any time. 

I have been given a chance to ask questions about the session and my questions have been answered. 

I agree to the fees discussed and fully understand that a cancellation fee of 50% of the full price of the treatment (before discounts) will be charged in the event of cancellation of treatment with less than 24-hour notice. Lateness up to 15 minutes will be deducted from my scheduled appointment time. After 15 minutes, I will be considered a no-show and will be charged according to Zen Head's cancellation policy (50% of the full price of the service). The entire staff is dedicated to client satisfaction, and Zen Head will send an appointment reminder prior to my scheduled service. Zen Head employs a no-refund policy (which also applies to product), and I am aware of this. 

I certify that I have read and initialed the above paragraphs and fully understand the above information. I accept full responsibility for these and/or any other complications which may arise or result during or following the treatment(s) which is to be performed at my request according to this consent. 


ZEN HEAD KC SPA POLICIES:

All retail and gift card sales are final. All services are final once completed, and no refunds will be issued.

Clients under age 18 must complete parental/guardian consent waiver. Clients under age 16 must have a parent/guardian present during their appointment.

We do not accept cash as payment for head spa and facial services.



Today's Date: April 3, 2026


PLEASE READ THIS IMPORTANT INFORMATION:

Please arrive to your appointment free of make-up and jewelry. You will have a heated eye mask on during a portion of your appointment.

Your treatment provider will step out of the room to allow you to undress to your comfort level and put on the spa wrap.

After your treatment, you will move to a comfortable chair under a hair dryer (optional) in the same treatment room for further relaxation. We do have hot tea, hair clips, and a handheld hair dryer available.

We are not able to perform a head spa treatment on hair that contains extensions.

Parkville clients: Please use the door code to Elevate Salon Studios provided in your confirmation/reminder text/email. If your provider is not at the front of the building to greet you, please wait in the waiting area inside the door.

Leawood clients: Usually your provider will be at the front of the Image Studios building to greet you; however, sometimes the previous appointment might have gone longer than expected for various reasons. When you arrive, please wait for your provider in the waiting area at the back right of the building.

Please select who will be participating...
AdultMinor
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Client Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
First Client Name
First Name*
Last Name*
Phone*
First Client Date of Birth*
Date of Birth
Intake and Consent Form
Are you currently pregnant?*
No
Yes
Have you ever had any issues with aromatherapy essential oils?*
No
Yes
Do you have any allergies or sensitivities?*
No
Yes
If you answered yes to any question, please elaborate.
Do you have any known scalp conditions, skin infections, diseases, viruses, or recent injuries/surgeries?*
No
Yes
If so, please describe:
Please describe your hair (check all that apply): *
Color treated (we are not responsible for changes in color due to the service)
Curly (if your hair is also long, please add the Zen Extra service to your appointment, as this will take longer)
Wavy
Straight
Dry
Dandruff
Oily
Extensions (**We are not able to perform a head spa treatment on hair with extensions.)
Because the scalp treatment/head spa includes some facial massage, please describe your skin: (check all that apply):
Congested (blackheads, tiny bumps, or skin is "clogged" but not necessarily oily)
Dehydrated (skin feels tight, like a "thirsty" plant, even if it gets oily later in the day)
Sensitized (you turn red if you even LOOK at a product)
Dull/Lacking Vitality (skin looks tired or gray)
Reactive (skin breaks out or gets itchy every time you try something new)
Mature/Depleted (skin needs extra nourishment)
Environmentally Stressed (dealing with wind, cold winter, or sun)
Have you been on Accutane in the last 6–12 months?*
No
Yes
Are you currently using any Retinols, Tretinoin, or Alpha Hydroxy Acids (AHAs)?*
No
Yes, I'm using retinols.
Yes, I'm using Tretinoin.
Yes, I'm using Alpha Hydroxy Acids (AHAs).
Have you had any cosmetic injections, fillers, or laser treatments in the facial area within the last 14 days? (it is recommended that you wait 2 weeks after Botox or fillers before having a facial.)*
No
Yes, I have had cosmetic injections in the facial area within the last 14 days.
Yes, I have had fillers in the facial area within the last 14 days.
Yes, I have had laser treatments in the facial area within the last 14 days.
Anything else we should know? (recent dental work, any issues with scalp or skin, etc.)
We'd love to know who/what brought you to Zen Head! *
Influencer
Our weekly email newsletter
Instagram
Facebook
TikTok
Internet search
Family member or friend
Found a business card, flier or coupon out and about
I hereby grant permission to Zen Head to use photographs or video of me taken during my head spa session on social media, on our website, or in advertisements.*
Yes, I Agree
No, I Do Not Agree
First Client Signature*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Intake and Consent Form
Are you currently pregnant?*
No
Yes
Have you ever had any issues with aromatherapy essential oils?*
No
Yes
Do you have any allergies or sensitivities?*
No
Yes
If you answered yes to any question, please elaborate.
Do you have any known scalp conditions, skin infections, diseases, viruses, or recent injuries/surgeries?*
No
Yes
If so, please describe:
Please describe your hair (check all that apply): *
Color treated (we are not responsible for changes in color due to the service)
Curly (if your hair is also long, please add the Zen Extra service to your appointment, as this will take longer)
Wavy
Straight
Dry
Dandruff
Oily
Extensions (**We are not able to perform a head spa treatment on hair with extensions.)
Because the scalp treatment/head spa includes some facial massage, please describe your skin: (check all that apply):
Congested (blackheads, tiny bumps, or skin is "clogged" but not necessarily oily)
Dehydrated (skin feels tight, like a "thirsty" plant, even if it gets oily later in the day)
Sensitized (you turn red if you even LOOK at a product)
Dull/Lacking Vitality (skin looks tired or gray)
Reactive (skin breaks out or gets itchy every time you try something new)
Mature/Depleted (skin needs extra nourishment)
Environmentally Stressed (dealing with wind, cold winter, or sun)
Have you been on Accutane in the last 6–12 months?*
No
Yes
Are you currently using any Retinols, Tretinoin, or Alpha Hydroxy Acids (AHAs)?*
No
Yes, I'm using retinols.
Yes, I'm using Tretinoin.
Yes, I'm using Alpha Hydroxy Acids (AHAs).
Have you had any cosmetic injections, fillers, or laser treatments in the facial area within the last 14 days? (it is recommended that you wait 2 weeks after Botox or fillers before having a facial.)*
No
Yes, I have had cosmetic injections in the facial area within the last 14 days.
Yes, I have had fillers in the facial area within the last 14 days.
Yes, I have had laser treatments in the facial area within the last 14 days.
Anything else we should know? (recent dental work, any issues with scalp or skin, etc.)
We'd love to know who/what brought you to Zen Head! *
Influencer
Our weekly email newsletter
Instagram
Facebook
TikTok
Internet search
Family member or friend
Found a business card, flier or coupon out and about
I hereby grant permission to Zen Head to use photographs or video of me taken during my head spa session on social media, on our website, or in advertisements.*
Yes, I Agree
No, I Do Not Agree
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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