Consultation Form

Skip to content

Facebook Instagram

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

Menu

Offers
Home
* Lymphoma Cancer *
About Us
Mobile Service & Treatments Prices
Book Appointment
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.

We use cookies to ensure that we give you the best experience on our website. If you continue to use this site we will assume that you are happy with it.Accept Decline Privacy policy