Name

Email Address

Address

Telephone

Postcode

Date Of Birth

Occupation

Are you currently under a doctor’s care and receiving ongoing treatment? Are you currently under a doctor’s care and receiving ongoing treatment? Yes No

Please list any medication or homeopathic supplements that you are currently taking

Do you suffering with any of the following? (please select all that apply) Do you suffering with any of the following? (please select all that apply) High/low blood pressure Heart condition/strokes/pacemaker Cancer/chemotherapy/radium Kidney/liver disorders Thrombosis Varicose veins/DVT Hepatitis Thyroid problems Haemophilia Respiratory problems I.E. Asthma Recent surgery (past 12 months) Pregnancy/IVF/breast feeding Haemorrhaging Hormonal imbalance Depression or anxiety Diabetes (type 1 or 2) Arthritis/rheumatism/osteoporosis Prosthesis/metal pins/plates/piercings Muscular pain Skin disorders/diseases Water retention/odema Poor circulation Acute or chronic back pain Skin sensitivity/allergies Migraine Ear/nose/throat infection Foot infections Claustrophobia Hepatitis B or C Epilepsy

List any health information that may affect or prevent you having a treatment

On a scale of 1 to 5 how stressed do you feel? (1 = Not stressed, 5 = Very stressed) On a scale of 1 to 5 how stressed do you feel? (1 = Not stressed, 5 = Very stressed)12345

What is your daily facial routine?

What are your 3 main concerns with your skin? Please tick What are your 3 main concerns with your skin? Please tick Ageing Redness Acne Fine Lines Sensitivity Congestion Dryness Open Pores Dark Circles Lack of Radiance Oily Other

What are your 3 main concerns with your body? Please tick What are your 3 main concerns with your body? Please tick Difficulty relaxing Lethargic Weight loss Skin conditions Muscle tension Water retention Weight gain Muscle cramps Cellulite Stretch marks Poor circulation Loss of firmness Dry skin

What massage pressure do you prefer? Light, medium, firm

hereby consent to the use of my personal data (including any sensitive personal data) for the purpose of my treatment and any future treatment and confirm that any treatment is at my own risk without limiting or affecting any statutory rights I may have. I agree that any dispute or claim that arise out of, or is related to, such treatment and/or spa services shall be subject to the law and the exclusion jurisdiction of the courts of the country/region in which the relevant treatment/service took place. hereby consent to the use of my personal data (including any sensitive personal data) for the purpose of my treatment and any future treatment and confirm that any treatment is at my own risk without limiting or affecting any statutory rights I may have. I agree that any dispute or claim that arise out of, or is related to, such treatment and/or spa services shall be subject to the law and the exclusion jurisdiction of the courts of the country/region in which the relevant treatment/service took place. Yes No

Please confirm that you or anyone in your household haven't had or been in contact with anyone who has had covid 19 in the last 14 days Please confirm that you or anyone in your household haven't had or been in contact with anyone who has had covid 19 in the last 14 days Yes No

Client Signature

Date