Client card to be completed before appointments

Client Card

* If you're a new client, to assist with your booking, please complete the client card form and email to us before your appointment. This will ensure we can deliver your treatement as soon as possible and all you'll need to do is relax and enjoy!

(* Indicates required fields)

Client Card Form

Title *

Name

Postal Address

Suburb *

State *

Postcode *

Home phone number *

Email *

Occupation

Date of Birth

Refered by

Do you suffer from any skin disorders? (If yes please specify)

Do you suffer from any allergies? (If yes please specify)

Do you have sensitivity to massage/essential oils? (If yes please specify)

Are you currently undergoing chemotherapy or radiation? (If yes please specify)

Are you currently taking any medications, herbs or vitamins? (If yes please specify)

Have you ever used Roaccutane or any other acne medication? If yes please specify

Have you ever been diagnosed with any of the following?

What are your present skincare or body care concerns? (Eg aging, pigmentation, acne, cellulite or aches and pains)

Have you ever had any surgery or operations? (If yes please specify)

Do you have any current injuries, pain or areas of discomfort? (If yes please specify)

Do you have any body implants? (If yes please specify)

Do any of the following apply to you?

If so, how often?

How many glasses of water do you consume daily?

Is there any other health related information that you wish to disclose? (If yes please specify eg 1st trimester in pregnancy)

For women only…

The above information is true and correct. Client Signature: Date:

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Spa Vitality