Bellevue Spa Consultation Form

MM slash DD slash YYYY

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Medical Information

Conditions: Please indicate if you are suffering from any of the following

Medical Information List(Required)
Are you Pregnant?(Required)

If Yes, how many weeks?

Do you wear a hearing aid?(Required)

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Lifestyle

Do you smoke?
Are you using products containing Retinol A or AHAs?
Contact lenses
Preferred Massage Pressure

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Consent(Required)