Spa Consultation Form

Spa   C onsultation   F orm  

 

Name:   _ __________________________________________   D ate   o f   B irth:   _ _________________  

Address:   _ ______________________________________________________________________  

Contact   N umber:   _ __________________________________Email   A ddress:   _ ________________  

Doctors   A ddress:   _ _______________________________________________________________  

Emergency   C ontact:   _ _____________________________________________________________

 

 

Is   t his   y our   f irst   v isit   t o   C loud   N ine   S pa   ?  

 

 

 

 

Yes   (   )   No   (   )  

 

Do   y ou   s uffer   f rom   a ny   o f   t he   f ollowing   m edical   c onditions?  

(   )   A llergies  

 

(   )   A sthma  

 

(   )   B ack   P roblems  

(   )   N erve   D amage      

 

(   )   D iabetes        

(   )   C ancer    

 

(   )   L oss   o f   s ensation  

(   )   H igh/Low   B lood   P ressure  

(   )   E pilepsy      

(   )   O ther  

If   y es   p lease   g ive   d etails   _ _________________________________________________________________  

 

Are   y ou   g oing   t hrough   a ny   o f   t he   f ollowing?  

(   )   P regnancy    

(   )   B reast   F eeding  

(   )   P ain   i n   a ny   a rea  

  (   )   H eadaches/Migraines  

(   )   O ther  

If   y es   p lease   g ive   d etails   _ _________________________________________________________________  

 

Medical   H istory?  

( If   y es,   p lease   d etail):  

Are   y ou   o n   a ny   M edication?            

     

 

            Y /N   _ __________________________________                                                    

Is   t here   h istory   o f   f amily   i llness?    

 

 

            Y /N   _ __________________________________  

Have   y ou   h ad   a ny   r ecent   s urgery,   a ccidents   o r   i njuries?       Y /N   _ ___________________________________  

 

Skin   T ype   a nd   C oncerns:  

(   )   N ormal  

 

(   )   D ry    

 

(   )   C ombination      

(   )   O ily    

  (   )   H igh   C olour  

(   )   S ensitive    

(   )   S un   D amage    

(   )   L ines/Wrinkles    

(   )   D ark   C ircles/Puffiness  

 

Other   _ _______________________________________________________________________________  

 

Body   C oncerns:  

(   )   D ry   S kin    

 

(   )   C ellulite  

 

(   )   P oor   C irculation    

(   )   A ches/Pains    

 

Other   _ _______________________________________________________________________________  

 

Massage   P ressure:  

(   )   L ight    

 

(   )   M edium  

 

(   )   F irm    

 

(   )   D eep  

 

 

How   w ould   y ou   l ike   t o   f eel   a fter   y our   T reatment?   _ ____________________________________________

 

CONSENT   A ND   A GREEMENT    

I   c ertify   t hat   t he   a bove   s tatements   a re   t rue   a nd   c orrect   t herefore   I   g ive   m y   c onsent   a nd   a uthorization   f or  

my   t reatment   t o   b e   c arried   o ut.  

 

Client   S ignature:_________________________________________________________Date___________  

 

Therapist   S ignature:   _ ____________________________________________________Date____________