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Spa Online Consultation Form

"*" indicates required fields

Name*
Date of Birth*
Date of Treatment*
Time of Treatment*
:
Address*
Please Indicate If You Are Suffering From Any Of The Following*
Are You Pregnant?*
Are You Taking Any Medication Or Supplements?*
Have You Any Of The Symptoms Of Covid 19? (Cough, Fever, Breathing Difficulty, Loss Of Taste/Smell, Sore Throat , Runny Nose) **
If Yes To Any Of The Above Did You Consult A Doctor Or Medical Practitioner?*

Lifestyle

Do You Smoke?*
Do You Wear A Hearing Aid?*
Do You Wear Contact Lenses?*
What Is Your Current Home Skincare Routine? Please tick products you use:*
I hereby certify that the enclosed is true and correct and that I use the facilities and services at my own risk and do not hold Chill Spa or any of its employees responsible. I also understand that I am kindly requested to reschedule my appointment if I am experiencing any flu like or Covid-19 symptoms.*
I wish to receive information on Chill Spa news, events & offers.