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CLIENT CONSULTATION FORM
"
*
" indicates required fields
Step
1
of
5
20%
First Name
*
Surname
*
Gender
*
Male
Female
Date of Birth
*
DD slash MM slash YYYY
Hidden
Physical address
Hidden
Home Tel
Hidden
Work Phone
Cell
*
Email
*
The purpose of the consultation form is to ensure correct evaluation of your skin care needs. The information is confidential and may only be disclosed to staff members to assess the quality of care and will not be passed on to any third party.
FACIAL CONSULTATION
Have you been under the care of a physician or dermatologist in the last year?
*
Yes
No
Are you currently using any medication?
*
Yes
No
Have you had any surgery (facial or other)?
*
Yes
No
Have ever had a chemical peel, dermabrasion or laser treatment?
*
Yes
No
What facial massage pressure do you prefer?
*
Light Pressure
Medium Pressure
Firm Pressure
What, if any, concerns do you have about your skin?
Redness
Dryness
Signs of premature ageing
Breakout
Oiliness
Dark circles
Puffiness
Other
Have you ever had a reaction or allergy to the following?
Cosmetics
Medicine
Iodine
Pollen
AHAs
Latex
Animals
Fragrance
Sunscreens
Essential oils
Food
BODY CONSULTATION
Have you had a massage before?
*
Yes
No
Are you pregnant, planning pregnancy or breastfeeding?
*
Yes
No
Are you on any medication or under medical supervision?
*
Yes
No
Please Specify:
What facial massage pressure do you prefer?
*
Light Pressure
Medium Pressure
Firm Pressure
MEDICAL BACKGROUND
Please tick if the following is relevant:
Under / Overactive thyroid
High cholesterol
Heart conditions
Epilepsy
Spinal Injury
Respiratory conditions
Hysterectomy
Headaches
High or low blood pressure (under medication)
Blood vessel disorder
Metal implants / pacemaker
Cancer
Asthma
Hormone imbalance
Bruising
Other skin disease
Please Specify other Skin Disease
INDEMNITY CONCERN AND DECLARATION
I, the undersigned, hereby:
1. Agree to abide by all the rules, regulations and etiguette that apply to the use of the facilities at the Labadi Beach Hotel Spa as recorded in notices displayed at the Labadi Beach Hotel Spa; and
2. Indemnify and agree to hold harmless the Labadi Beach Hotel Spa, its officers, employees, directors, shareholders, agents and / or contractors against:
i) All claims made or brought against any one or more of them, by or on behalf of myself and/or any of my dependants and /or any person utilizing such facilities as my guests or invitee and/or any person for whom I have agreed to pay as a user for such facilities or omission or condition, and whether as a result of recklessness, for any harm, injury, losses and /or damages (both direct and indirect) suffered or sustained and /or for any expense or cost incurred in or about Labadi Beach Hotel Spa and /or its facilities, regardless of the cause thereof, including but not limited to any act or omission or condition, and whether as a result of recklessness, negligence or otherwise;
ii) All costs and expenses (including legal cost on an attorney and own client basis) incurred by any one or more of them in resisting, opposing or defending and one or more of such claims to finality.
I hereby declare that I have completed the above consultation form accurately and that I have not withheld any information that may be relevant to my treatment. The Therapist will not be held liable in any way whatsoever.
Signature
*
Date Submitted :
Comments
This field is for validation purposes and should be left unchanged.
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