Spa Consultation Form

Title *
—Please choose an option—MissMrsMrMsMxOther

First name *

Last name *

Mobile number *

Email address *

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Treatment name *

Treatment date *

Treatment time *

Please indicate if you have, or have previously experienced, any of the following symptoms? *
Back ProblemsEczemaDepressionArthritisHyperthyroidMigraine HeadachesIrritable Bowel SyndromeConstipationAsthmaClaustrophobiaRheumatismMenopausePsoriasisNone of the Above

Please indicate if you have, or have previously experienced, any of the following symptoms? *
AllergiesLow Blood PressureDiabetesHigh Blood PressureCancerEpilepsyHeart ConditionsNone of the Above

Please let us know any allergies you may have

Have you had surgery in the last 6 months? *
YesNo

Are you pregnant or breastfeeding? *
YesNo

Are you currently taking any prescribed medication? *
YesNo

If you answered yes to any of the above, please confirm you will inform your therapist in more detail prior to your treatment

Please confirm if you are feeling any of the following? *
High Temperature (above 38 degrees)New and Continuous CoughLoss of Taste/SmellSomeone in your household showing COVID-19 symptomsNone of the Above

How would you rate your stress level? *
LowMediumHigh

Is your sleep disturbed or of poor quality? *
YesNo

Can you confirm you are over 18 years? *
YesNo

Please indicate below to accept the Cwrtium Spa terms and conditions
*I accept that Cwrtium Spa will not be held liable or responsible for any treatment side effects that may occur as a result of the treatment received.