First Name *

Last Name *

Phone *

Email *

Address

Street Address *

City *

State *

Country

Postal Code *

Emergency Contact Name *

Relationship *

Emergency Contact Phone *

Physician Contact Name

Physician Contact Phone

Physician Contact Address

In the event, we cannot contact you by the means you have provided above, we would like to know if we have permission to speak to your spouse or significant other about your treatment. By giving the information below you are giving us permission to speak with your spouse or significant other about your treatment.

Spouse Contact Name

Spouse Contact Phone

If someone referred you, please list referral:

Biological sex at birth (for clinical assessment purposes *

Male

Female

Biological Sex

Consent & Waiver

Clinical Photo & Video Release: *

Marketing & Education: I authorize the use of my photos/videos for social media, website, and educational training.

Education Only: I authorize use for medical/trichology training and case studies only (identities obscured).

Private File Only: Photos are to remain strictly in my private clinical record for tracking progress only.

Media Release Acknowledgement *

I understand that Spiritually Loc’d may document my hair journey. I grant permission for the use of media as per my selection above.

Clinic Policies Confirmation *

I confirm that I have received, read, and agree to the Spiritually Loc’d clinic policies, including cancellation and service protocols.

Trichology Scope of Practice & Results Disclaimer *

I understand that Natalie Tirado is a Certified Trichologist, not a medical doctor. These services are non-medical assessments of the hair and scalp. I acknowledge that while professional recommendations are provided, specific results or total hair regrowth are not guaranteed

HIPAA Privacy Acknowledgment *

I acknowledge that my health information is protected and stored in a secure, HIPAA-compliant environment. I consent to the electronic storage and transmission of my intake data for the purpose of my consultation.

Trichology Hair Service Release Waiver

I authorize and release Natalie Tirado (Spiritually Loc'd) from any pre-existing hair loss problems as they relate to my hair loss and scalp disorders. I further release Spiritually Loc'd from any lawsuits or claims that arise in relation to any services I may receive. I grant permission for Natalie Tirado to receive any information necessary from my previous stylists or medical professionals.

I understand I am financially responsible for all charges and services. I acknowledge that while professional recommendations are provided for the health of my hair and scalp, Natalie Tirado provides precautionary measures and knowledge; she does not provide medical diagnoses or guaranteed results. I knowingly and willfully assume all risks and responsibilities and hold Spiritually Loc'd harmless with respect to all hair loss issues and health issues.

Signature *

Clear

Date of signature *