Consultation Form

    Basic Information

    • Name
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    • Email
      Please enter a valid email address
    • Mobile
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    • Home Telephone Number
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    • Date of Birth
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    • Type of residence
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      • Hotel Resident
      • Day Guest
    • Reason for your visit
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    • Where did you hear about us?
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    • Occupation
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    Medical Information

    • Please tick any of the following that applies to you
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      • Diabetes
      • Epilepsy
      • High/low blood pressure
      • Heart Conditions
      • Pacemaker
      • Poor Circulation
      • Undiagnosed lumps
      • Cancer (In the last 5 years)
      • Recent scar tissue
      • Metal pins and plates
      • Thrombosis
      • Muscle problems/injuries
      • Skin diseases
      • Fungal infections
      • Psoriasis
      • Prescribed medication
      • Arthritis
      • Eczema
      • Dermatitis
      • IBS
      • Wart/Verruca
      • Athletes foot
      • Claustrophobia
      • Depression
    • If you have ticked any of the above, please give details
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    • Any other medical conditions?
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    • Have you had an operation in the last 12 months?
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    • If you have circled yes, please give details
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    • Do you suffer from any allergies or have you ever had an allergic reaction?
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    • If you have circled yes, please give details
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    Ladies only

      Please inform your therapist if you are pregnant so the correct treatment can be advised and carried out. Treatments can only be carried out from 12 weeks – 32 weeks.

    • Are you pregnant?
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    • If yes, how many weeks?
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    • Are you breast-feeding?
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    • Do you have any concerns about your pregnancy that your therapist should be aware of?
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    Facial and Skin Analysis

    • Please tick any of the following that applies to you
      Please fill this in
      • Dry
      • Oily
      • Fine lines & wrinkles
      • Sensitive
      • Pigmentation
      • Dull
      • Combination
      • Acne
      • Scarring
      • Rosacea
      • Blocked pores
      • Dark circles
      • Thread veins
      • High colour
      • Cellulite
      • Aches & pains
      • Lack of muscle tone
      • Overweight
    • Please list any other concerns you may have that are not listed above
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    • Do you currently have a skincare routine?
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    • If yes, what is your routine?
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    • Please let us know where you have any areas of concern and areas you want us to concentrate on
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    Mailing

    • Join Our Treatment Rooms Mailing List
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    Disclaimer

      Declaration 

      I declare to inform my therapist at The Norfolk Mead Treatment Rooms of any adverse reactions including but not limited to redness, itching or irritation that occurs following my patch test.

      Please can you make sure all the information given above is correct, true and up to date. At the Norfolk Mead Hotel Treatment Rooms, we will not be held responsible for any consequences of being given false information or no information at all, which may affect specific treatments. All treatments are for general purposes and not intended for substitution of medical procedures. 

      Please note: We will never share your personal information with any third parties and all information supplied will only be used for the purpose of your treatment, All personal information is only accessible to our Therapists and Reservation teams. You may view your personal file at any time via our Therapists. 

    • Name
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    • Date
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