Consultation Card

Name

Date of Birth

Address

Contact Number

Occupation

Reason for Treatment

How did you hear about The River Spa?

With your permission, we will use your email address for all future marketing purposes. Please complete here.

Submit

Please answer Yes or No to the following questions

 

Medical History – Have you ever been diagnosed with the following?

Cancer

Yes

No

Asthma

Yes

No

Heart Condition

Yes

No

Migraine

Yes

No

High Blood Pressure

Yes

No

Low Blood Pressure

Yes

No

Depression

Yes

No

Allergies

Yes

No

Hormone Imbalance

Yes

No

Do you smoke?

Yes

No

Skin type

Dry

Oily

Sensitive

Combination

Do you use the following?

Cleanser

Toner

Exfoliator

Mask

Eyecare

Moisturiser

Pregnancy Treatment Consultation Form

What week of pregnancy or post partum are you?

Single or multiple pregnancy?

Have you every been diagnosed with a complication or high risk condition in this pregnancy or previous pregnancy or postpartum?

If yes, please specify

Send

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