Bloxham Salon Health Questionnaire by Cedar Therapy

Salon*

Bloxham

Title*

Mrs
Ms
Miss
Mr
Lady
Other/MX

Name*

First Last

Email*

Customer Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date Of Birth

Telephone

Mobile*

Well Being Questions

Are you currenlty afected by any of the following conditions? Please check the following boxes:

If you checked any of the answers above then please provide more detail:

Do you have any allergies?*

Yes
No

Please Specify Allergy:*

Do you have any Skin Conditions?*

Yes
No

As some treatments include a foot spa please advise if you have a verrucae, athletes foot or you are affected with any other foot infection.

Please specify skin condition:*

Are you taking any medication?*

Yes
No

Please specify medication:*

Signed:*

Contact Permission*

We'd love to send you exclusive offers and events and the latest info from Cedar Therapy by Email, SMS, Post and other electronic means. We'll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes.

Yes please, I'd like to hear about exclusive offers and events
No thanks, I don't want to hear about exclusive offers and events

Bloxham Salon Health Questionnaire

Health Questionnaire - Bloxham Salon

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