Home / Spa online consultation SPA ONLINE CONSULTATION FORM Name* First Last Email Date of Birth* DD MM YYYY Date of Treatment* DD MM YYYY Time of Treatment* : HH MM Treatment Description (Treatment booked)Address* Address Phone*Please Indicate If You Are Suffering From Any Of The Following* Cancer any Lymph Nodes removed, radiated or Damaged? Heart Condition High/Low Blood Pressure Recent Operation Joint Problems Muscular Pain Seizures/Epilepsy Thyroid Problems Diabetes Iodine Sensitivity Poor Circulation Skin Sensitivity Allergies (Nut Etc.) Product Allergies Asthma Psoriasis Cuts, Bruises and Abrasions Water Retention Claustrophobia Acne Eczema Warts Verucas None Of The Above Other Please Specify Other Please SpecifyAre You Pregnant?* Yes No If Yes, How Many Weeks?Are You Taking Any Medication Or Supplements?* Yes No Have You Any Of The Symptoms Of Covid 19? (Cough, Fever, Breathing Difficulty, Loss Of Taste/Smell, Sore Throat , Runny Nose) ** Yes No If Yes To Any Of The Above Did You Consult A Doctor Or Medical Practitioner?* Yes No LifestyleDaily Consumption of Plain Water*Sleep Patterns*Do You Smoke?* Yes No Do You Wear A Hearing Aid?* Yes No Do You Wear Contact Lenses?* Yes No What Is Your Current Home Skincare Routine?*Please tick products you use: Cleanser Toner Exfoliator Day Cream Night Cream Eye Product Face Masks Serum Body Exfoliator Body Moisturiser Botox Peels Injectables/Fillers None Of The Above 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 agree I wish to receive information on Chill Spa news, events & offers. Tick this checkbox if you wish to receive SIGN UP FOR OUR NEWSLETTER SUBSCRIBE
