Crantock Bay Spa

Consultation Form

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* 1. Name:

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* 2. Date of Birth:

Date / Time

Date

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* 3. Address:

Address

Address 2

City/Town

County

Post Code

Email Address

Phone Number

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* 4. Emergency Contact Number:

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* 5. Do you suffer from any of the following:

Allergies including food

Diabetes

Epilepsy/Fainting/Seizures

Back Problems or pain

Eczema/Dermatitis/Psoriasis

High/Low blood pressure

Nerve damage

Heart conditions

Circulatory problems

Headaches or migraines

Any surgery in the last 12 months

Pregnant or breast feeding

Any history of cancer

Taking any medication

Other

If you have ticked any boxes please give details below:

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* 6. I hereby confirm that neither I, nor anyone within my household are showing Covid-19 symptoms, nor have been around anyone who has tested positive in the last two weeks. I do not have a high temperature, a new consistent cough or loss of taste or smell.

Yes

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* 7. Consent and agreement
I certify that the above statements are true and correct, therefore I give my consent for my treatment to be carried out.

Yes

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* 8. Please go to our website to view our privacy policy: https://www.crantockbay.co.uk/privacy-policy/

Yes

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* 9. Due to the nature of our business and while we take steps to minimise the risk of cross contamination, we cannot guarantee that any of our products are safe for people with nut, wheat or other severe allergies.

Crantock Bay Spa

Consultation Form

Question Title

* 1. Name:

Question Title

* 2. Date of Birth:

Question Title

* 3. Address:

Question Title

* 4. Emergency Contact Number:

Question Title

* 5. Do you suffer from any of the following:

Question Title

* 6. I hereby confirm that neither I, nor anyone within my household are showing Covid-19 symptoms, nor have been around anyone who has tested positive in the last two weeks. I do not have a high temperature, a new consistent cough or loss of taste or smell.

Question Title

* 7. Consent and agreementI certify that the above statements are true and correct, therefore I give my consent for my treatment to be carried out.

Question Title

* 8. Please go to our website to view our privacy policy: https://www.crantockbay.co.uk/privacy-policy/

Question Title

* 9. Due to the nature of our business and while we take steps to minimise the risk of cross contamination, we cannot guarantee that any of our products are safe for people with nut, wheat or other severe allergies.

* 7. Consent and agreement
I certify that the above statements are true and correct, therefore I give my consent for my treatment to be carried out.