SPA CONSULTATION FORM

Please complete the form below ahead of your stay













    Your details

    Title:

    Date of birth:

    Anything you think we should know about?

    Lifestyle

    Are you taking any medication? YesNo
    Are you breastfeeding? YesNo
    Do you exercise regularly? YesNo
    Is there a history of family illness? YesNo
    Do you smoke? YesNo
    Is your sleep disturbed? YesNo

    Medication

    Skin Story

    Skin type

    Skin concerns/ conditions

    Skincare routine

    What skincare brand(s) do you currently use?

    Which of the following skincare products do you regularly use?

    Do you regularly use any other product(s)? YesNo

    Have you recently undergone any intensive facial treatments (such as dermabrasion, laser, a chemical peel or any other)? YesNo

    Have you ever used Roaccutane, Accutane or Retinin A? YesNo

    Have you recently had any cosmetic enhancements, such as botox, fillers or any other? YesNo

    Massage/ body treatments

    Are there any particular areas that you would like to concentrate on or avoid during your treatment?

    Your permission

    I confirm and agree that any treatment(s) undertaken at The Spa at The Harper are at my own risk, other than in relation to any physical or mental harm I suffer due to negligence. I acknowledge and agree to the collection, use and disclosure of my personal data and health information. I hereby confirm that the information provided herein is accurate and complete.

    Please sign in the box below





    If you are a child aged 16 or 17, you will need parental consent. Please ask your parent to check and sign this form, below:

    Full terms and conditions can be found on our website.

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