Home / Spa online consultation SPA ONLINE CONSULTATION FORM Name* First Last Date of Birth* DD MM YYYY Date of Treatment* DD MM YYYY Time of Treatment* : HH MM AM PM Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Please Indicate If You Are Suffering From Any Of The Following* Cancer 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 Have You Been In Contact With Someone Who Has Symptoms Of Covid-19 Or A Confirmed Case Of Covid-19 In The Last 14 Days?* Yes No Have You Had A Positive Test For Covid-19 ? (Or Are Awaiting Test / Test Results) In The Last 14 Days.* Yes No Have You Been Advised To Isolate Or Restrict Your Movements In The Last 14 Days? (Including Because Of Recent Travel Abroad* Yes No If Yes To Any Of The Above Did You Consult A Doctor Or Medical Practitioner?* Yes No Do You Agree To Having Your Temperature Taken Upon Arrival To Chill Spa?* Yes No Do You Consent To Wearing A Mask/Face Covering During Your Treatment?* 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 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 or if I have been in contact with anyone that has tested positive for Covid-19 in the last 14 days.* I agree SIGN UP FOR OUR NEWSLETTER SUBSCRIBE
