Health Declaration

IN ORDER TO MAXIMISE YOUR TIME IN THE TREATMENT ROOM PLEASE COMPLETE THIS FORM AND RETURN IT BY EMAIL AT LEAST 48 HOURS PRIOR TO YOUR APPOINTMENT. WE DO NOT WISH TO LOSE TIME FROM YOUR TREATMENT SHOULD THE FORM HAVE TO BE COMPLETED ON YOUR ARRIVAL.

Full Name

Please describe any current health conditions e.g. heart, blood pressure, epilepsy, DVT, stroke etc.

Please describe any skin complaints, conditions or foot infections e.g. eczema, psoriasis, verrucas etc.

Please tell me if you have any muscular aches, pains or joint problems e.g. back, knee, arthritis etc.

Please let me know if you are pregnant, have any implants, allergies, recent surgery, Botox, fillers etc.

Date

Signature

IMPORTANT INFORMATION

We would ask that you kindly read the following -

• PLEASE ATTEND THE TREATMENT ROOM a few minutes prior to your scheduled appointment in order to prepare for your treatment and so that we may start on time. If the door is closed, please take a seat on the landing.

• PLEASE DO NOT ATTEND IN MUDDY OR WET OUTDOOR SHOES. There is not always time to hoover the carpet between clients.

• PLEASE USE THE HOTEL TOILET FACILITIES OR YOUR ROOM FACILITIES prior to arrival as we have no toilet facilities upstairs.

• PLEASE LEAVE JEWELLERY, WATCHES etc. in your room.

• MOBILE PHONES should be on SILENT.

• PREGNANCY - PLEASE NOTE that no treatments can be carried out during the first trimester.

• BOTOX AND FILLERS - no facial treatments can be carried out within 3 weeks of having Botox or facial fillers.

• PLEASE DO NOT ATTEND IF YOU ARE SICK OR SHOW ANY SYMPTOMS OF COVID 19 we will refuse service and you will be liable for the full cost of the treatment.

I declare that I have not withheld any information regarding my health and agree that I am happy to continue with the scheduled treatment.

I confirm that the information I have given on this form is true and that by booking this appointment I agree that I have read and understood the above procedures and am happy to adhere to them.

Thanks for submitting!

SKINSENSE

ART OF MASSAGE

At the Inn at Whitewell

SK-INtuition

®

100% NATURAL SKINCARE

©

Hand Made by Kay

Holistic Massage and Facial Treatments for Ladies and Gentlemen based at the beautiful Inn at Whitewell

Health Declaration

IN ORDER TO MAXIMISE YOUR TIME IN THE TREATMENT ROOM PLEASE COMPLETE THIS FORM AND RETURN IT BY EMAIL AT LEAST 48 HOURS PRIOR TO YOUR APPOINTMENT. WE DO NOT WISH TO LOSE TIME FROM YOUR TREATMENT SHOULD THE FORM HAVE TO BE COMPLETED ON YOUR ARRIVAL.