Gold Zanzibar Consultation Form

Consultation Card

Name:

Room number:

E-mail:

Male/Female:

Country of origin:

Please take a moment to read the following information carefully and sign where indicated. If you have a specific medical condition or specific symptoms that may be affected by the treatment, a referral from your doctor may be required prior to the service being provided.

Have you ever experienced a professional face or body treatment?

YesNo

If yes, how recently?

Do you suffer from any medical condition?

YesNo

If yes, please specify:

Are you pregnant?

YesNo

Do you have high blood pressure?

YesNo

Do you have have any allergies?

YesNo

If yes, please specify:

Have you ever experienced a reaction to a skin product?

YesNo

Have you ever experienced a reaction to a skin product?

DryOilyCombination

What kind of pressure would you prefer?

SoftMediumStrong

Is there anything else that we should know before starting your treatment?

*I agree to receive communication from Healing Earth, in line with the POPI Act:

YesNo

Signature:

Date:

Comments (Spa only):

DISCLAIMER NOTICE/INDEMNITY:
Guest/s who use the various treatment facilities and equipment and utilize this facility does so at their own risk. The Propriety, its agent/s and/or its employee/s ("the Proprietor”) shall not be liable for, and the guest/s hereby waive/s and abandon/s any claims of whatever nature including but not limited to that for theft, injury, loss or damage of whatever nature, against the Proprietor, whether, arising from the Proprietor's default, negligence or otherwise. The guest/s, in addition to the aforesaid, hereby indemnify the Proprietor against claims which may arise from whatever nature, whether arising from the Proprietor's default, negligence or otherwise. This disclaimer notice is included in.