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online spa consultation form
online Spa Consultation Form
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Please fill out the form.
Booking Reference Number
*
Date and time of treatment
*
What treatment/package have you booked?
*
Name
*
Date Of Birth
*
DD
/
MM
/
YYYY
Address
*
Telephone Number
*
Email Address
*
Medical Information
Conditions
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
Joint Problems
Asthma
Psoriasis
Cuts, bruises and abrasions
Water Retention
Claustrophobia
Acne
Eczema
Warts
Verrucas
If you answered yes to any of the above, please provide more detail
Are you Pregnant?
*
Yes
No
If Yes, how many weeks?
Please note treatments are not suitable during the first trimester of pregnancy and some treatments are not suitable at all during pregnancy for example Hot Stone Massage
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)
*
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
Lifestyle
Daily consumption of plain water
*
Sleep patterns
*
Do you smoke?
*
Yes
No
Are you using products containing Retinol A or AHAs?
*
Yes
No
Do you wear
Hearing aid?
*
Yes
No
Contact lenses
*
Yes
No
What is your required slipper size?
*
Do you agree to having your temperature taken upon arrival to The Spa at The Kingsley?
*
Yes
No
Which Aromatherapy Shower would you like?
Relax
Energise
Would you like to add any extras to your spa booking? (Booking of extras is not confirmed until you receive email confirmation)
Kingsley Aroma Candle E23 ( RRP E28)
Afternoon Tea E25pp (RRP E30pp)
Glass of Prosecco E6 (RRP E8.50)
Mini Scalp E25 (RRP E40)
Foot Massage E25 (RRP E40)
*
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 The Spa at The Kingsley 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
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