SPA & WELLNESS

Admire Consultation Form

Please complete prior to your visit to our spa.

Important: The below information is being used to allow our therapists to prescribe the perfect treatment for you. Your information will not be used for any other purpose unless you specify otherwise.

Date of Treatment

Name of Treatment Booked

Full Name (that the treatment was booked under)

Contact Number

Date of Birth

Email Address

Occupation

Guest Type

Health & Medical History

Do you suffer from any of the following medical conditions? (Please tick as appropriate)

Allergies / Reactions

Please provide details

Skin Complaints

Please provide details

Cancer Chemotherapy / Radiotherapy Diabetes Epilepsy High / Low Blood Pressure Hyperthyroid Heart Condition Multiple Sclerosis Thrombosis / Phlebitis Eye Infections Athletes Foot Verruca Varicose Veins

Are you on any medication or under medical supervision?

Have you had recent surgery, accidents or injuries?

Have you had / used any of the following in the last 2 weeks? (Tick as appropriate)

Botox/Dermal Fillers Facial Peels/Facials

Please provide details of anything else you feel we should know to support your treatment?

Skin Types & Concerns (for facials only)

How Would You Describe Your Skin?

What are your main skin concerns? (Tick as appropriate)

No concerns Blemishes Combination / Oily Dry / Dehydrated Dull / Lack of radiance Fine lines & wrinkles Lifting & firming Pigmentation / Uneven skin tone Puffiness / Dark circles Sensitive Smoothing / Resurfacing

How many products do you use in your skincare routine?

What is your current daytime skincare routine? (Tick as appropriate)

None Cleanse Tone Moisturise Exfoliate Mask Eye Treatment Other

If "Other" please specify

What is your current night-time skincare routine? (Tick as appropriate)

None Eye make-up remover Cleanse Tone Moisturise Serum Mask Neck Treatment Eye Treatment Other

If "Other" please specify

If you would like to receive information on offers or discounts, please specify below.

How did you hear about us?

If "Other" please specify

Client Declaration

By ticking the following box I am acknowledging that I have answered the above questions to the best of my knowledge in preparation should any special care be needed throughout your treatment. I understand that staff have the right to refuse or withdraw their service at any stage. This does not effect my statutory rights. I have not withheld any information that may effect the effectiveness of the treatment and wish to proceed.

I accept the client declaration and wish to proceed.

Contact Permission

Yes please, I'd like to hear about your offers and services No thanks, I don't want to hear about your offers and services