Spa Consultation Form

Client Details

Title: *

Full Name: *

Address: *

Email: *

Contact Number: *

Date of Birth: *

How did you hear about us? *

How would you like to receive special offers and promotions for the spa? *

Email Text Mail I do not want to receive offers/promotions

Medical Information

Do you have any medical conditions? *

Please list: *

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or trying to become, pregnant? *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Contact Relationship: *

Lifestyle

What would you say your current stress level is?

Please rate the quality of your sleep:

How often do you exercise?

Do you smoke?

How many cigarettes per day?

Do you drink any alcohol?

How often?

What is your daily water intake?

Skin

Fitzpatrick skin types:

1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker colour and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

Which of the above skin types would you say is closest to your skin?

How would you describe your skin?

Normal Sensitive Dry Oily Combination Scaly

What are your skin concerns? Please tick all that apply.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I receive at the spa is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) from treatment(s) received and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a spa treatment.

Client Signature: *

Tap or click on the signature above to sign