Wellness Form - Nobu Hotel London Portman

Full Name(Required)

Email(Required)

Phone Number(Required)

Date Of Birth(Required)

Occupation

Emergency Contact Name & Number

Are you currently under medical supervision?(Required)

Yes

Are you currently taking any medication or using any medicated ointment? If Yes, please list.

Please let us know if you have any conditions.

Is there anything else about your health history that you think would be useful for your therapist to know to plan a safe and effective treatment for you?

Do you have any skin condition – bruises, eczema, open wound?

Yes

Are you wearing contact lenses, dentures, hearing aid?

Yes

Please state any specific areas you would like the massage therapist to focus on during the session:

What type of skin do you have?

What areas of concern do you have regarding your skin?

Have you been under the care of a dermatologist within the past year or are?

Yes

Please specify if you have any allergies.

Do you currently or have you used in the last 3 months Retin-A, Renova, AHAs or Retinol/Vitamin A derivative products? If yes, please specify.

By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge and agree to inform the therapist of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the therapist of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my therapist and the employer for any injury or damages incurred due to any misrepresentation of my health history. I understand that sexual misconduct, intoxication, and unruly behaviour causing disturbance to other guests and Wellness team members will not be tolerated and rights of admission are reserved. I agree to respect the dignity of employees and not to cause any situations which could result in treatment having to be terminated.