Health Questionnaire - Momo Fish Spa

MOMO FISH SPA HEALH QUESTIONNAIRE Please inform us if you applied any sun lotion or cream to your lower legs today.

Name: ……………………………………….………………... Date of Birth (DD/MM/YYYY): …………………………………

Address: …….………………………………………………………………………………………………….……………………..………

…………………………………………………………………………………………………………………… Post code: ……..………..

Telephone: ……………………………………………..… E-mail:………………………………………………………………………

Emergency contact details: ………..………………………………………………………………………………………………….

 In the past 24 hours, have you…

…applied any nail varnish or fake tan? Yes No

…applied any lotion or cream to your lower legs? Yes

…shaved or waxed your lower legs? Yes No

 Have you undergone any surgery in the past 12 months? Yes No

 Are you currently under a physician’s care for any skin condition? Yes No

If yes, please give details: …………………………………………………………………………………………………..

 Please tick if you are affected by or have any of the following:

Psoriasis Dermatitis Hepatitis

Eczema Rosacea Hepatitis A

Asthma High Blood Pressure Verrucas/ Warts

Diabetes Heart Disease Open Wounds

Epilepsy Blood Clots/Phlebitis ANY immune deficiency

Friendly reminder: if you have a verruca, athletes foot, fungal infection, open wounds, or scabs, then you won’t be allowed to have a fish pedicure until your condition is completely healed – this is in the best of interests of both our customers and our fish. Thanks for your understanding. Acknowledgement & Agreement I hereby acknowledge and agree to the terms of the disclaimer set out below and where the client information set out above relates to a person younger than 18 years old I can confirm that I am the parent/legally appointed guardian of that person, or I am authorised to sign this form in loco parentis by the parent or legally appointed guardian. I certify that the above information is true to the best of my knowledge. I hereby assume full responsibility for the payment of any and all services rendered by MOMO Ltd. and will pay the full amount in advance for any services to be provided to me by MOMO Ltd.

Signature: ………………………………………………….. Date: ……../……../……..……..

Print Name: ………………………………………………..

Disclaimer:

MOMO Ltd makes no reservation about the suitability of the services that it provides. MOMO Ltd hereby disclaims all warranties and conditions with regards to the information, products and services supplied to it including all implied warranties and conditions of merchantability and fitness of a particular purpose to the extent that it is entitled to do so under the law of the island of Jersey. In no event shall MOMO Ltd be liable for any direct, indirect, incidental, special or consequential damages arising out of or in any way connected with the products or services which it provides save to the extent required under the law of the Island of Jersey.

Would you like to receive email updates about our special offers? Yes No For more information and links to our Facebook page where you can stay up to date with our latest offers, please visit: http://momofishspa.com

Thanks! See you again soon!

For staff use only

Treatment time: ………………… Amount: ………………… Method of payment: …………………

Gift voucher number: …………………………………… Other: ………………………………………………………………….

Staff Member: ………..……………………… Date: ………/………/……………… Time: ……………………….