Client Card Daddy Wellness

Please fill out the below form before starting your treatment.

Contact Details

Select the Mommy Wellness branch you are visiting*

Date of Treatment*
Full Name*
Telephone Number*
Email Address*

Covid-19 Details

Do you have fever (temperature above 38 degrees Celsius, or have you felt hot or feverish recently (14-21 days)?*
YesNo
What is your current temperature?*
Do you have shortness of breath or any difficulties breathing?*
YesNo
Do you have a cough?*
YesNo
Any other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*
YesNo
Have you experienced recent loss of taste or smell?*
YesNo
Have you been in contact with any confirmed COVID-19 positive persons?*
YesNo
Are you over 65 years of age?*
YesNo
Do you have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?*
YesNo
Have you traveled in the past 14 days to any regions affected by COVID-19?*
YesNo

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:
Emergency Contact Name:
Emergency Contact Number:
Email Newsletter Sign-up:
YesNo
SMS Promotions Sign-up:
YesNo
Would you like to receive Whatsapp Broadcast Messages with new or exclusive special promotions? *selected branches only:
YesNo

Medical History

Recent surgery/operations within the last 6 months:
Are you under medical care/supervision?
YesNo
Please specify if yes:
Recent skin resurfacing treatments (laser/peels):
Allergies:
Medications:
Please tick where applicable:
Multiple SclerosisVaricose VeinsThrombosisHigh Blood PressureLow Blood PressureDiabetesClaustrophobiaHeadaches/MigrainsEczemaPsoriasisEpilepsyAsthmaAnaemiaOedemaUlcersSinusitusThyroid ImbalanceHeart DiseaseKidney DiseaseCancerInfectious DiseaseHormonal ImbalanceFibromyalgiaPacemaker

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)Hot Stones (R90 extra)15 Min Scalp Massage (R110 extra)15 Min Foot Massage (R110 extra)15min Hand Massage (R110 extra)Express Mani or Pedi (R121 extra)Alginate Mask (R110 extra)Lip or Brow Thread (R88 extra (selected branches))Lip or Brow Wax (R88 extra (selected branches))Alginate Mask (R110 extra)

Where did you hear about us?

CompetitionEntertainerEventFacebookGift VoucherGoogleHealth SpaMediaLocal MarketingInstagramMediclinicWebsiteWord 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.