Day Spa & Beauty Consultation Form - Riverhills, Ipswich, Suffolk

Note: The following information is required for your safety and to benefit your health. The following details will be treated in the strictest of confidence. If you are or have suffered from any of the following: epilepsy, embolism, cancer or diabetes, it will be necessary for you to obtain the approval from your GP prior to treatment. Minors under the age of 16 need to be accompanied by an adult for treatments and the consultation must be signed by the main caregiver.

About you
Date of your visit to Riverhills*
DD slash MM slash YYYY
Title*
First name*
Last name*
House name / number*
Street*
Address line 2
Town / City*
County
Post Code*
Email*
Telephone number
Date of birth*

Day
Month
Year
Would you like to receive offer emails from us?
- Yes
We only send around 1 email per week and you can unsubscribe at any time.

Skincare
Do you use products containing retinal A or AHAs (Alpha Hydroxy Acid)?
- Yes
- No
Have you had Botox injections?
- Yes
- No
Have you had any permanent make-up?
- Yes
- No
Are you currently having any forms of treatment?
- Yes
- No
Includes chiropractic, osteopathy, homoeopathy, acupuncture, etc.

IT IS NOT ADVISABLE TO HAVE AN AROMATHERAPY TREATMENT:
On the same day as other alternative therapies, eg. chiropractic, osteopathy, homoeopathy, acupuncture

Within 24hrs of innoculation

Within 24hrs of sunbed treatment

If you are or have suffered from epilepsy

If you are pregnant

Please advise prior to treatment if any of the above apply.
Client declaration*
- I declare that the information I have given is correct, and as far as I am aware I can undertake treatment without any adverse effects. I have been advised about contra-indications and I am willing to proceed with the treatment.
Name
This field is for validation purposes and should be left unchanged.

Consultation Form