Health Declaration

Fields marked with * are required. Please select "N/A" if a question does not apply to you.

1. Personal Details

Date of Birth

Date of Treatment

2. Health Questionnaire

Please tick if any of the following medical conditions apply:

Cancer/Chemotherapy Heart Conditions/Strokes High/Low Blood Pressure Thyroid Problems Epilepsy Diabetes (Type 1 or 2) Pregnancy/IVF/Breastfeeding Recent Operations Depression/Anxiety Joint Problems / Muscular Pains Asthma Varicose Veins/DVT Recent Cosmetic Surgery Foot Infections Other None / N/A

Are you taking any medication? N/A

Any allergies or intolerances? N/A

Prescriptive medication on the skin? N/A

Using active products (Vitamin A, Glycolic, etc)? N/A

Any other medical conditions? N/A

3. Treatment Preferences

Music Preference:

Nature Sounds Chilled Out Country Retreat Cottonmill Signature Classic Unwind Gentle Jazz

Preferred Pressure:

Light Medium Firm

4. Confirmation & Signature

I confirm that I have disclosed all relevant information to Cottonmill Spa for the purpose of my treatment and any future bookings. I agree that any treatment is at my own risk without limiting or affecting my statutory rights.

Please sign below:

cottonmillspa.com

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