Peake Spa Pre-treatment questionnaire

Name*
First Last
Date of birth*

DD/MM/YYYY
Address*

Including postcode
Email*
Phone*
In case we need to contact you in advance of your appointment.
Consent to receive spa marketing emails
- Please tick here if you would like to receive emails regarding special offers or the latest beauty news
Please tick here if you do not wish to receive emails regarding spa special offers or the latest beauty news
- Allergies* e.g. lanolin, latex, nuts
- Epilepsy
- Open wounds
- Arthritis
- Fever
- Osteoporosis
- Asthma
- Fibro myalgia
- Recent scar tissue
- Back/neck problem
- Fungal disease
- Rosacea/sensitive skin
- Bruises/broken capillaries
- Heart conditions/pacemaker
- Skin disorder
- Cancer*
- Heat sensitivity
- Sunburn
- Cold sores/herpes
- High/low blood pressure
- Thrombosis
- Contagious conditions/disease*
- Metal pins/plates
- Thyroid problem
- Diabetes
- Multiple sclerosis
- Varicose veins
- Other*
*Please provide additional information
Are you currently pregnant or undergoing fertility treatments*
- Yes
- No
Please disclose any prescription medication that you are currently taking
Have you had any advanced skincare treatments in the past two weeks?*
- Yes
- No
Do you be wearing contact lenses?*
- Yes
- No
CAPTCHA
Consent
I confirm that, to the best of my knowledge, the answers above are correct and I have not withheld any relevant information. I hereby agree to assume all risk and responsibility and to hold the Spa and its employees harmless in the event I sustain any injury or damage to my person, directly or indirectly, as a result of my receiving services and I further agree to release the Spa and its employees from any claim, cause of action, damages, etc. that may be result from any such injury or damage. PLEASE NOTE: We regret that we cannot be responsible for the loss or damage of personal articles. Please keep all valuables with you during your services.
Name
First Last
Date
MM slash DD slash YYYY

Peake Spa Pre-treatment questionnaire

Ahead of your visit please complete the pre-treatment questionnaire below

Peake Spa Pre-treatment questionnaire

Celebrating 50 Years!

Peake Spa Pre-treatment questionnaire

Ahead of your visit please complete the pre-treatment questionnaire below

Peake Spa Pre-treatment questionnaire

Celebrating 50 Years!

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