Spa Registration Form | Cowley Manor

Name*
First Last
Treatment Date*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Health Check
- Do you have a high temperature?
- A new continuous cough?
- A change/loss of your taste or smell?
- None of the above
Guest Details*
- Hotel Resident
- Day Visitor
- Spa Member
What is the reason for your treatment with us?
Is there anything specific you are currently dealing with?

For the ladies:

Are you pregnant, planning a pregnancy, or just recently had a baby?	If you have recently had a baby- how long ago was this, and are you currently breast feeding?	If yes; how many weeks pregnant are you?

Do you suffer with any known allergies at all?
Is stress or anxiety a factor in your home/work life?
How well do you sleep? How many hours per night?
How regularly do you exercise? If applicable, what do you do?
Are you currently taking any medication or under any medical supervision?
Have you had any surgery/non-invasive or botox included within the last 6 months?
How is your diet? Are you a vegan/vegetarian? Eat plenty of meat, fish, grains, fruit, vegetables?
How much water do you drink a day?
How much alcohol do you drink per day?
How much time do you spend on a computer, phone or tablet a day? Do you take the time to get up and take a break by a small walk?
- I am happy to receive marketing communications by Cowley Manor
Name
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