Consultation Form - Face Body Day Spa & Beauty Salon

Date(Required)

Name(Required)

First Last

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Age(Required)

Gender(Required)

Where did you hear about us?(Required)

Would you like to receive information via email regarding the Day Spa?(Required)

Medical

Are you under medical supervision or alternative treatment?(Required)

If selected "Yes" above, please give details.(Required)

Are you talking any prescribed medication, herbal remedies or vitamins?(Required)

If selected “Yes” above, please give details.(Required)

Have you suffered any recent injuries trauma or undergone any surgery in the last 12 months?(Required)

Do you have any known allergies?(Required)

If selected “Yes” above, please give details.(Required)

Are you currently suffering from any of the following?(Required)

For Males Only

Are you taking any form of oestrogen, progesterone contraception?

Are you pregnant or trying to become pregnant?

If selected “Yes” above, number of weeks.

Are you lactating?

Are you currently going through menopause?

Lifestyle

Have you ever had a spa body treatment before?(Required)

Do you drink more than 2 units of alcohol and coffee(Required)

Do you drink more than 4 glasses of water everyday?(Required)

Do you have regular sleep patterns?(Required)

Do you wear contact lenses?(Required)

Have you ever experienced claustrophobia?(Required)

Have you been sunbathing in the last 24 hpurs?(Required)

Skin Care: Facial Only

When was your last facial treatment?(Required)

Have you had a chemical peel, laser, microdemabrasion in the last month?(Required)

Are you using product containing AHA's or Vitamin A?(Required)

Do you have tendency to redness/sensitivity?(Required)

Which of the following concerns for you?(Required)

Which of the following currently do you use?(Required)

Do you use sunscreen/sunblock on your skin?(Required)

For Males Only

What is your currently shaving system?

Do you experience irrigation from shaving?

Do you experience ingrowing hairs?

I inform to the best of my knowledge that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment(Required)

I inform to the best of my knowledge that the answers I have given are correct and I have not withheld any information that may be relevant to my treatment

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