Spa Consent 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: *

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