Name *

First Name

Last Name

Date Of Birth *

Please enter the month then the day.

MM

DD

YYYY

Have you experienced any Covid symptoms in the last 14 days? *

Please tick all symptoms that apply.

None

Fever or temperature

Cough or respiratory symptoms

Loss of taste or small

Fatigued

Other

Have you been in contact or living with someone suspected or confirmed to have had coronavirus? *

No

Yes, they are now fully recovered

Yes, they are not fully recovered

Please check any health conditions which you have ever had previously or are now experiencing:

You can check multiple boxes

Heart Condition

Thrombosis Phlebitis

Pacemaker

Blood Pressure - High

Blood Pressure - Low

Varicose Veins

Hepatitis

Diabetes

Epilepsy

HIV / Aids

On HRT

Thyroid Issues

Pregnant

Muscle / Joint Disorder

Metal Plates / Pins

Postnatal, Less than 6 weeks

Skin Problems

Skin: Psoriasis / Eczema / Dermatitis

Botox or Collagen

Fungal Infections

Recent Major Surgery

Cosmetic Laser Surgery

Chemotherapy / Radiotherapy

Asthma / Breathing Difficulties

Migraines

Back Problems

Adverse Reaction to Essential Oils

Hayfever / Sinus Issues

Living with Cancer

Are you currently pregnant? *

Yes

No

Please indicate the treatments you are booked for *

Check any boxes that are applicable

Massage

Facial

Manicure or pedicure

Waxing or tinting

Fitness

Please can you let us know where you heard about us? *

Check as many boxes as you like.

Internet search

Social media

Friend or family

Holiday home provider

Other

We would like to contact you via email from time to time about our latest thoughts and offers around at-home wellness. You can opt out of this by ticking the boxes below.

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