Full Name *


Date of Birth *

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Date and Time of Treatment *

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Address *




Telephone number *

Email Address *

Please Indicate If You Are Suffering From Any Of The Following *

Are You Pregnant? *

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? *

Lifestyle

Daily Consumption of Plain Water *

Sleep Patterns *

Do You Smoke? *

Do You Wear A Hearing Aid? *

Do You Wear Contact Lenses? *

What Is Your Current Home Skincare Routine? *

Please tick products you use:

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 Escape Spa or any of its employees responsible. *