Client Intake | SCALPS

A personal welcome

Welcome to SCALPS®

Your details, health history, signature and deposit—one short step at a time.

8–10

MinutesSet aside a little uninterrupted time.

$100

Reservation depositPaid securely at the end.

By selecting Begin secure intake, I acknowledge that I’m sharing my private contact and health information with SCALPS. Required answers are marked *.

02 · About you

Let’s start with the essentials.

Use the information you want associated with your confidential SCALPS client record.

First name * Last name * Date of birth * Occupation Street address * City * State * ZIP code * Mobile number * Email address *

03 · Your goals

Tell us where you’re starting.

These answers help us understand the look you want and any previous hair or scalp work.

What would you most like treatment to accomplish? *

Hairline definitionCreate or refine a shaved-look hairline. DensityReduce visible contrast through thinning areas. Scar camouflageVisually soften a transplant or injury scar.

How long have you been losing your hair? *

Have you had a hair transplant? *

YesNo

Please tell us what type and when.

Are you using hair-loss products, systems, medication, or lotions? *

YesNo

Please list them.

How did you hear about SMP? How did you hear about SCALPS?

Photography acknowledgement * I understand that SCALPS may take photographs before, during, or after treatment. If I do not want photographs taken, I will let my practitioner know before photography begins.

You may decline photography. This acknowledgement records that the choice was explained; tell your practitioner if you do not want photos taken.

04 · Medical history

Anything that could affect treatment or healing.

Select every condition that applies. Choose “None of these” if the list does not apply to you.

Do you have, or have you previously had, any of the following? *

Please select at least one answer.

Are you currently receiving treatment for any condition? *

YesNo

Please describe the treatment.

Have you taken medication during the last six months? *

YesNo

Please list each medication.

Have you taken aspirin or ibuprofen during the last two days? *

YesNo

Allergies, including latex * Previous cosmetic procedures * Physician name Physician phone Physician address

05 · Review

One clear review before you sign.

Choose a section to go back and make changes before you sign.

Designed to avoid silent mistakes.

The production version will validate every required answer again on the server before payment or PDF creation.

06 · Agreement

Read, confirm, and sign.

Review the agreement and sign below. Next, you’ll choose how to pay your $100 deposit.

SCALPS client consentDeposit policy · DEPOSIT-2026-09-08

In signing below, I give my consent to proceed with scalp micropigmentation treatment and confirm that I have read and agreed to the SCALPS Terms and Conditions and Privacy Policy in advance, or on the treatment day with sufficient time to review them.

I confirm that the information in this intake is complete and accurate to the best of my knowledge. I understand that I must tell SCALPS about any relevant change before treatment.

Deposit cancellation and refund policy: The $100 reservation deposit is refundable only if SCALPS receives my cancellation request at least seven (7) calendar days before my scheduled procedure date. If SCALPS receives my cancellation request fewer than seven (7) calendar days before my scheduled procedure date, or if I do not appear for the scheduled procedure, the entire $100 deposit is forfeited and will not be refunded. By signing below and authorizing payment, I acknowledge and agree to this cancellation and refund policy.

I understand that my drawn signature, typed legal name, signing date and time, IP address, and the version of this agreement will become part of the completed electronic record.

Read Terms and Conditions ↗Read Privacy Policy ↗

Legal name * Date signed *

Draw your signature *

Use your finger, mouse, or stylus. Your signature will appear in the completed intake PDF.

Please add your signature before continuing.

07 · Reservation deposit

Finish with one secure $100 payment.

Your signed agreement is saved. Choose a payment option below to finish.

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Manually enter your card number

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What happens next

You’ll see a confirmation once your payment is verified. Our team will contact you to schedule your sessions.

Confirmation

Your intake and deposit are complete.

We’re excited to work with you. You’re in good hands with SCALPS, and we’ll guide you through what comes next.

A member of our team will contact you to schedule your sessions. In the meantime, read your pre-care instructions. You’ll also receive them by email.

Submission referencePendingYour $100 deposit and signed intake have been received.