Consultation Form Date(Required) MM slash DD slash YYYY Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Email(Required) Age(Required)Under 2121 - 3031 - 4041 - 5051 - 60Above 60Gender(Required)MaleFemaleOtherWhere did you hear about us?(Required) Would you like to receive information via email regarding the Day Spa?(Required)YesNoMedicalAre you under medical supervision or alternative treatment?(Required)YesNoIf selected "Yes" above, please give details.(Required)Are you talking any prescribed medication, herbal remedies or vitamins?(Required)YesNoIf selected “Yes” above, please give details.(Required) Have you suffered any recent injuries trauma or undergone any surgery in the last 12 months?(Required)YesNoDo you have any known allergies?(Required)YesNoIf selected “Yes” above, please give details.(Required) Are you currently suffering from any of the following?(Required)DiabetesEpilepsyHigh/Low Blood PressureFor Males OnlyAre you taking any form of oestrogen, progesterone contraception?YesNoAre you pregnant or trying to become pregnant?YesNoIf selected “Yes” above, number of weeks. Are you lactating?YesNoAre you currently going through menopause?YesNoLifestyleHave you ever had a spa body treatment before?(Required)YesNoDo you drink more than 2 units of alcohol and coffee(Required)YesNoDo you drink more than 4 glasses of water everyday?(Required)YesNoDo you have regular sleep patterns?(Required)YesNoDo you wear contact lenses?(Required)YesNoHave you ever experienced claustrophobia?(Required)YesNoHave you been sunbathing in the last 24 hpurs?(Required)YesNoSkin Care: Facial OnlyWhen was your last facial treatment?(Required) Have you had a chemical peel, laser, microdemabrasion in the last month?(Required)YesNoAre you using product containing AHA's or Vitamin A?(Required)YesNoDo you have tendency to redness/sensitivity?(Required)YesNoWhich of the following concerns for you?(Required)AgingBreakoutsCongestionDrynessSensitivityDehydrationOtherWhich of the following currently do you use?(Required)CleanserExfoliatorMoisturiserTonerMasqueEye CreamSerumDo you use sunscreen/sunblock on your skin?(Required)YesNoSPFFor Males OnlyWhat is your currently shaving system?WetElectricDo you experience irrigation from shaving?YesNoDo you experience ingrowing hairs?YesNoI 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 Signature Δ