Consultation Form

Name

Contact number

Address

Name of emergency contact and phone number

Date of Birth

Please list any medical conditions (including pregnancy), injuries or health concerns you have?

Please list any allergies you have or any reactions?

Please list any medications you are taking - (also include contraception, homeopathic or natural remedies or topical creams)

Have you had any surgery, botox treatments or fillers and if so when? Please note there are some treatments we are unable to perform within certain time frames of these treatments?

What would you most like to get out of your treatment today?

If attending for a facial what are your main skin concerns?

If attending for a massage, what pressure do you prefer?

Is there anything else you would like to find out about?

Please feel free to leave any comments/messages here. Thank you so much for filling out the form and choosing Chillout Spa.

Newsletter, promotions and information updates - Thanks for keeping me up to date with relevant information via newsletters or relevant emails.

Acknowledgement - I acknowledge that the information provided by me in this form is true and correct, and I have not withheld any information that may be relevant to my treatment. I acknowledge that it is my responsibility to inform Chillout Spa of my medical conditions and medication, and to disclose any changes to the above information. I agree Chillout Spa is entitled to rely solely on the information provided in this form. I consent to this treatment and to any other treatments I may have in the future.

Address

Submitted

CHILLOUT SPA

Meadowbank
Auckland 1072
New Zealand

OPEN HOURS

By appointment only

Monday - Saturday
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For more times available please contact me directly.

Email me here

Consultation Form

CHILLOUT SPA

OPEN HOURS

PARTNERS