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Claremont
Durbanville
East London
Krugersdorp
Sea Point
Strand / Somerset West
Paarl
Plumstead
Westlake
Date of Treatment
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Personal Details
Please complete the rest of the form only if your details have changed / you are a new client / you have not been with us within the past 12 months
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Would you like to receive Whatsapp Broadcast Messages with new or exclusive special promotions? *selected branches only:
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Medical History
Recent surgery/operations within the last 6 months:
Are you under medical care/supervision?
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Please specify if yes:
Recent skin resurfacing treatments (laser/peels):
Allergies:
Medications:
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Spider Veins
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Are you currently pregnant/trying to conceive?
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If currently pregnant, how many weeks?
Due Date
Is this your first pregnancy?
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If not, how many children do you have?
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Do you have any specific skin/body concerns?
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Where did you hear about us?
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Terms and Conditions
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I confirm that to the best of my knowledge, the answers I have given are correct and I have not withheld any relevant information. Mommy Wellness Day Spa and/or any of their respective members, employees and representatives are not liable for any loss, damage, injury or expense of any nature whatsoever arising from the use of any products and/or services that is provided by Mommy Wellness Day Spa. I agree to be personally responsible for the payment of all and every cost relating to my booking(s) at the spa, use of spa facilities and/or products purchased.
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