Chillout Spa

Chillout Sculpting Buccal Massage

Please note that there are some contraindications for this treatment, so kindly please complete this form.

Name

Phone number

Address

Name of Emergency Contact and their Contact Number

Date of Birth

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

Do you have cancer, diabetes or are using blood thinning medications?

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)

If you have used roaccutane or similar, when was the last time you took this medication?

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

Do you currently have active acne, rosacea, broken capillaries, bruising, cuts or abrasions, cold sores or thin/fragile skin in the facial area?

Have you had any chemical peels and if so when?

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

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

Message Sent.

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

Chillout Sculpting Buccal Massage

CHILLOUT SPA

OPEN HOURS

PARTNERS