Consultation Form

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Consultation Form
- Covid 19 Guidelines

Offers
Home
* Lymphoma Cancer *
About Us
Mobile Service & Treatments Prices
Buy A Gift Card
Payment Page
Leave a Review
Contact Us
- Privacy Policy
Consultation Form
- Covid 19 Guidelines

Due to Covid-19, we must receive your completed Consultation Form before your appointment date.

First Name

Last Name

Contact Number

Date Of Appointment

Your Email

Do you suffer from the follow - If Yes please give full information in box below

High Blood Pressure Diabetes Epilepsy Arthritis Migraines Fibromyalgia Back Problems Skin Disorder Cancer

Are Your Pregnant?

Yes No

Do you have a routine for your skin?

Yes No

DO YOU HAVE ANY OF THESE SYMPTOMS?

Cough Shortness of Breath High Fever Muscle Pain Body Ache Nausea Loss of Taste/Smell

Yes No

PLEASE CONFIRM THE BELOW

By completing the boxes, you confirm that you agree with the following statements.

I confirm that within the last 14 days I have not been in contact with anyone that has COVID-19 symptoms or got infected?

I confirm that I have not been diagnose with COVID-19 in the last 14 days.

I verify that I am not waiting for the laboratory test results for COVID-19

Are you living with anyone that has got infected or quarantined due to COVID-19?

Yes No

Signature Required

I agree not to visit the Spa for any reason of the services provided if I have the symptoms of COVID-19. I acknowledge that the information I have given on this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.

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