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?

Have you any of the symptoms of Covid-19? (cough, fever, breathing difficulty, loss of taste/smell, sore throat, runny nose)
Have you had a positive test for Covid-19 (or are awaiting test / test results) in the last 14 days?
Have you been advised to isolate or restrict your movements in the last 14 days? (including because of recent travel abroad).
If yes to any of the above, did you consult a doctor or medical practitioner?

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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)