IKINUKI / ASAKUSA

Pre-Visit Consultation Form

To help us provide a safe and comfortable treatment, each guest completes this form individually. If you are visiting as a pair, please submit one response per guest. This takes about 3 minutes.

Booking Information

Booking nameREQUIRED

Please fill this in.

Guest nameREQUIRED

Please enter the name you would like us to use.

Please fill this in.

Appointment date and start timeREQUIRED

Please select a date and time.

Number of guests in your bookingREQUIRED

One guest Two guests

Please choose one.

Language for your visitREQUIRED

Japanese English

※For English guidance, our therapists may use simple English, prepared English materials and translation tools.

Please choose one.

Hair and Scalp

What is your hair type?REQUIRED

Straight Wavy Curly Coily Not sure

Please choose one.

What is your hair length?REQUIRED

Short Medium Long Extra-long

Please choose one.

Please select anything that applies to your hairREQUIRED

None Color-treated Bleached Permed Chemically straightened Dry or damaged Other

Please choose at least one.

Do you currently have extensions or a protective hairstyle?REQUIRED

No Removable extensions or hairpiece Tape-in extensions Braided or sew-in extensions Braids or cornrows Dreadlocks or locs Wig Hair transplant or hair enhancement Other Not sure

IKINUKI treatments require access to the scalp and include washing, massage and herbal oil. Depending on the hairstyle and attachment method, we may need to adjust or decline the treatment to prevent loosening, tangling or incomplete drying. Our team may contact you before your appointment.

Please upload a photo showing your current hairstyle.

Please choose one.

Please select anything that applies to your scalpREQUIRED

No concerns Dryness Itching Redness or irritation Flaking or dandruff Cuts, swelling or rash Sunburn Other

Please choose at least one.

Health and Safety

Is there anything we should consider before your treatment?REQUIRED

No Pregnant or possibly pregnant Injury or significant pain in the head, neck or shoulders Cuts, swelling, rash or severe scalp irritation Receiving treatment for a skin or scalp condition Recent surgery or major medical treatment Advised to avoid massage or heat treatments Other information we should know

Please tell us anything we need to know to adjust your treatment. You do not need to provide a detailed diagnosis.

Please choose at least one.

Have you ever had an allergy or skin reaction to cosmetics or other products?REQUIRED

No Cosmetics or skincare products Shampoo or haircare products Fragrances or essential oils Herbal or botanical ingredients Pollen Nuts Metals Other Not sure

If known, please tell us which product or ingredient caused the reaction and what happened.

Please choose at least one.

Are there any ingredients you would like us to avoid?REQUIRED

Please tell us if there are any ingredients you would like us to avoid because of allergies, sensitivities or personal beliefs.

None Yes Not sure

Please choose one.

Are there any areas you would prefer us not to touch?REQUIRED

None Face A specific area of the scalp Neck Shoulders or décolletage Arms or hands Feet Other

Please provide any details necessary for your treatment.

Please choose at least one.

Current Concerns

Do you currently have any concerns related to your head or body?REQUIRED

Select all that apply.

Neck or shoulder tension Eye fatigue Heaviness in the head Difficulty sleeping or fully relaxing Facial or body puffiness Stress or tension Menstrual-cycle-related discomfort Scalp dryness or itching Dry or damaged hair No specific concerns Other

Please choose at least one.

Which concern is most important to you today?REQUIRED

Your therapist will use your answers to select a herbal oil blend suited to your needs on the day.

Please choose one.

Treatment Clothing

Please select your treatment T-shirt sizeREQUIRED

These are Japanese sizes. Please select one size larger if you prefer a relaxed fit.

S M L XL 2XL I would like to check the size on arrival

Please choose one.

Optional Guest Survey

The following questions are optional and will help us improve our services.

Age rangeOPTIONAL

Country or region of residenceOPTIONAL

Are you currently visiting or living in Japan?OPTIONAL

Visiting Japan from overseas Living in Japan Temporarily staying in Japan Other Prefer not to say

How did you first hear about IKINUKI?OPTIONAL

Who are you traveling with in Japan?OPTIONAL

Solo Partner Friends Family Group Other Prefer not to say

Where else will you visit during this trip?OPTIONAL

Tokyo only Kyoto Osaka Nara Hakone Mt. Fuji or Kawaguchiko Hiroshima Hokkaido Okinawa Other Not decided yet

Confirmation and Consent

I confirm that the information provided above is accurate to the best of my knowledge. I understand that the treatment may be adjusted, paused or declined depending on my physical condition, hair or scalp condition.

Please confirm to continue.

I consent to IKINUKI collecting and using the information provided for treatment safety, product selection and necessary communication.

Please confirm to continue.

I have read the privacy policy.

Please confirm to continue.

Thank you for completing the form.

Please contact us before your appointment if there are any changes to your physical condition, hair or scalp condition.

If we need additional information about extensions, braids, locs, hair transplants or hair enhancements, our team will contact you.

We look forward to welcoming you to IKINUKI.