Consultation Form

 

CONSULTATION FORM

Welcome to The Parlour Room, we look forward to treating you today!
Please fill in the below information so we can ensure your treatment is tailored to your every need.

NAME *
NAME
GENERAL INFORMATION
Is this your first time having this treatment?
Do you currently use any sunless tanning products?
Are you currently pregnant or trying to become pregnant?
Are you currently breastfeeding?
Have you ever had any chemical peels, laser or micro-dermabrasion?
Do you currently use any retinol or roaccutane products?
FACIALS INFORMATION
Do you smoke?
Please select your preferred massage pressure:
How would you describe the following?
Stress Levels
Exercise Frequency
Sleep Quality
Diet Quality
Water Intake
TERMS & CONDITIONS
Please read and confirm: *
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that is supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
EMAIL MARKETING *
I would like to keep up to date with The Parlour Room news, events and special offers via email. We respect your privacy - please find our full Privacy Policy and Terms & Conditions on our website.