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Date and time of treatment
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Name
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Date Of Birth
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Address
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Telephone Number
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Email Address
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Medical Information
Conditions
Please indicate if you are suffering from any of the following
Cancer
Heart Condition
High/Low Blood Pressure
Recent Operation
Joint Problems
Muscular Pain
Seizures/Epilepsy
Thyroid Problems
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Product Allergies
Joint Problems
Asthma
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Cuts, bruises and abrasions
Water Retention
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Fungal Infections
If you answered yes to any of the above, please provide more detail
Are you Pregnant?
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If Yes, how many weeks?
Please note treatments are not suitable during the first trimester of pregnancy and some treatments are not suitable at all during pregnancy for example Hot Stone Massage
Are you taking any medication or supplements?
If yes to any of the above did you consult a doctor or medical practitioner?
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Lifestyle
Daily consumption of plain water
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Sleep patterns
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Do you smoke?
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Are you using products containing Retinol A or AHAs?
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Do you wear
Hearing aid?
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Contact lenses
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Would you like to upgrade your experience to include a Glass of Prosecco for Eur 12pp
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Would you like to upgrade your experience to include a Mocktail for Eur 5pp
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Would you like to upgrade your experience to include a Sensory Heated Eye Mask for Eur 6pp
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Would you like to upgrade your experience to include a The Spa at The Kingsley Branded Flip Flops Eur 4.50pp
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No
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I hereby certify that the enclosed is true and correct and that I use the facilities and services at my own risk and do not hold The Spa at The Kingsley or any of its employees responsible.
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