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Health Questionnaire

1
Personal Details
2
Address
3
Health Questions
4
Consent
Title *
First Name *
Surname *
Email *
Phone Number *
Date of Birth *
Please fill in your personal details before proceeding.
Address Line 1 *
Address Line 2 (Optional)
City *
County *
Postcode *
Country *
Please fill in your address details.
Health Conditions
Do you have any allergies? *
Please provide details of your allergies
Do you have any skin conditions? *
Please provide details of your skin conditions
Are you taking any medication? *
Please provide details of your medication
Are you booking in for a facial treatment? *
What is your skin type? *
What is your secondary skin concern? *
What is your primary skin concern? *
Let us know your sensitive skin symptoms: *
Please provide more info:
How do you currently take care of your skin?
Are you pregnant? *
When is your due date?
How many times do you shave your face per week (if applicable)
If any, specify your skin concerns related to shaving:
Recent Treatments & Conditions (Select all that apply - doctors release form required)
Do you suffer from chronic tendonitis? *
Do you have metal plates implanted in your body? *
Have you been diagnosed with heart disease? *
Do you suffer from an inflammatory skin disease? (e.g. Herpes, melanoma, carcinoma, lymphoma) *
Do you suffer from high blood pressure? *
Do you suffer from epilepsy? *
Do you suffer from fibromyalgia? *
Have you had Botox and/or hyaluronic acid injections or filler in the last month? *
Any additional notes?
Please fill in all required fields.
Please confirm which salon you would like to attend. *
Would you like to stay informed about our curated offers and discounts?

Your Permission
I hereby consent to the use of my personal data (including any sensitive personal data) for the purpose of my treatment and any future treatment. It is my responsibility to inform my Beauty Therapist of any of my pre-existing conditions, limitations or specific sensitivities, and to inform her or him if I feel any discomfort during the session. I understand that if I expose myself to any of the products, services, or items listed on this release form and do not inform my Beauty Therapist, or choose to proceed against my Beauty Therapist’s recommendation, I am accepting full responsibility for any possible reaction. I have read the above information and give my permission to my Beauty Therapist to perform the procedure, and I agree to hold my Beauty Therapist and the spa harmless of any liability that may result from this treatment.

Please draw your signature in the space below *
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