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Urban Teen Treatments
Babe, Tot & Tween Treatments
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Branches
Claremont
Durbanville (Head Office)
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Paarl
Plumstead
Sandton
Sea Point
Somerset West
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Please fill out the below form before starting your treatment.
Full Name
Telephone Number
Email
Select the Mommy Wellness branch you are visiting
Select...
Alberton
Claremont
Durbanville
Somerset West
Bahrain
Date of Treatment
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
Personal Details
Address
Date of Birth
Occupation
Marital Status
Select...
Single
In a relationship
Married
Divorced
Widow
Emergency Contact Name
Emergency Contact Number
Email Newsletter Sign-up
Yes
No
SMS Promotions Sign-up
Yes
No
Would you like to receive Whatsapp Broadcast Messages with new or exclusive special promotions? *selected branches only:
Yes
No
Medical History
Recent surgery/operations within the last 6 months:
Are you under medical care/supervision?
Yes
No
Please specify if yes:
Recent skin resurfacing treatments (laser/peels):
Allergies:
Medications:
Please tick where applicable:
Spider Veins
Varicose Veins
Thrombosis
High Blood Pressure
Low Blood Pressure
Diabetes
Claustrophobia
Headaches/Migrains
Eczema
Psoriasis
Epilepsy
Asthma
Anaemia
Oedema
Ulcers
Sinusitus
Thyroid Imbalance
Heart Disease
Kidney Disease
Cancer
Infectious Disease
Hormonal Imbalance
Irregular Menstrual Cycle
Breastfeeding
Are you currently pregnant/trying to conceive?
Yes
No
If currently pregnant, how many weeks?
Due Date:
Is this your first pregnancy?
Yes
No
If not, how many children do you have?
Skin/Body
Do you have any specific skin/body concerns?
Please share your current skin/body regime:
Would you like to add on the following services?
Add-ons only available if time allows
Paraffin Dip (R55 extra)
Footlogix Foot Treatment (R160 extra)
Brow Tint (R96 extra)
Lash Tint (R96 extra)
Hot Stones (R90 extra)
15min Scalp Massage (R110 extra)
15min Foot Massage (R110 extra)
15min Hand Massage (R110 extra)
Express Mani or Pedi (R121 extra)
Lip or Brow Thread (R88 extra (selected branches))
Alginate Mask (R110 extra)
Where did you hear about us?
Competition
Entertainer
Event
Facebook
Gift Voucher
Google
Health Spa
Media
Local Marketing
Instagram
Mediclinic
Website
Word of Mouth
If Other, please specify
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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