CLIENT DETAILS / INDEMNITY FORM Name* First Name * Last Name * ID Number*Area of ResidenceEmail* Mobile*Place of WorkSelect Branch*SelectKitisuruGigiriDate of Birth* DD MM YYYY Yes, I’d like to receive Serenity Spa’s newslettersYes, I’d like to receive Serenity Spa’s newslettersHave you had a spa treatment before?YesNoCurrent skin care products used?What would you like to achieve from your treatment today?What are your main areas of concern, if any?MEDICAL HISTORY (tick where applicable) Acne Arthritis Artificial implants Asthma Blood disorder (circulation) Blood thinner Cancer Claustrophobia Cuts / Abrasions / Bruising Depression Distended capillaries/veins Diabetic Eczema Epilepsy Fever blisters Heart condition Hepatitis High blood pressure Low blood pressure HIV/AIDS Hyper pigmentation Hypo pigmentation Hyper thyroid Hypo thyroid Insomnia Insulin resistant Laser treatment Lupus Metal plates or pins Nail disorders Nerve damage Pacemaker Phlebitis Plastic surgery Pregnant - weeks [ ] Psoriasis Retinol A (or brand name) Scleroderma Seborrhoea Scar Tissue Skin disorders Surgeries Swelling / Oedema Varicose veins List any further medical conditionsDISCLAIMERI confirm* Serenity Spa treatments are provided for general relaxation purposes only and are not intended to be a substitute for professional medical treatment for any condition, medical or otherwise.Serenity Spa and its management and staff hold no responsibilities on all liabilities, claims, expenses, damages and losses, including legal fees, arising out of or in connection with the spa treatments, services and/or facilities.I confirm and agree to fully indemnify and hold harmless Serenity Spa, it’s holding company(ies), affiliates, subsidiaries, agents, staff and suppliers, from and against all liabilities, claims, expenses, damages and losses, including legal fees, arising out of or in connection with all and any spa treatments, services and/or facilities received by me. This also includes any treatments or advice received on the premises from third parties including independent consultants. Signature
