Consultation Form Your Details Name * First Name Last Name Email * Date of Birth * Phone * Country (###) ### #### Male Female Prefer not to say Your Appointment Date of Spa Appointment * MM DD YYYY Please confirm the full names of who you are attending with * Spa Day Treatment * If you have booked a spa package, please select a single treatment from the options below. Select N/A if you have booked spa only or a standalone treatment. The Willow Signature The Willow Hot Stones Willow's Ultra-Hydration Facial Sole Serenity Full Body Detox Scrub Indian Head Massage Pregnancy Massage Pregnancy Facial N/A Treatment Only If you are visiting the spa for a standalone treatment, please select a treatment from the options below. Select N/A if you have booked a spa package. The Willow Signature The Willow Hot Stones Willow's Ultra-Hydration Facial Sole Serenity Full Body Detox Scrub Indian Head Massage Pregnancy Massage (45 minutes) Pregnancy Facial (45 minutes) Self Care Strength & Support Bloom & Glow Pregnancy Treatment N/A Medical History Medical Conditions * Please select any that apply to you and provide more information in the box below None Cancer [currently or within past two years - please provide more information] Inflammation / Swelling [please provide more information] Blood Clots Any contagious disease or illness Chronic pain High Blood Pressure Other [please specify] Please provide more information on any medical conditions Please list any medications you are currently taking * Have you had any medical procedures or surgeries within the past 18 months? * Do you have any skincare or medication allergies? * Pregnancy Are you pregnant? * Yes No If you are pregnant, please confirm the number of weeks you will be on the date of your appointment Dietary Requirements Do you have any dietary preferences? * Do you have any food allergies? * Additional Information Please note, you may wish to bring more than one piece of swimwear to ensure your comfort as our spa facilities include moving through both wet and dry rooms. Is there any other information you would like to share with us to enhance your spa experience? Thank you for completing our consultation form.
