Pre-Treatment Questionnaire

about you

Name *

First Name *

Phone *

Email address *

Date of birth *

about your health

Do you have allergies ? *

Do you have allergies ?: Yes No

What are your allergies ?

Are you pregnant ? *

Are you pregnant ?: Yes No

How many months ?

Do you have any cardiac or blood circulation disorders?

Do you have any cardiac or blood circulation disorders?: Yes No

Are you under any medical care or recovering from illness?

Are you under any medical care or recovering from illness?: Yes No

Which one?

Did you have any surgery over the last past months? *

Did you have any surgery over the last past months?: Yes No

What was it?

Is there anything else you would like us to know?

I hereby testify:

Discharging the Therapist as well as the Spa of the Hotel Le Bristol Paris, of any responsibilities resulting to present or future disorder or pathology occurring after a massage or a care. *

Discharging the Therapist as well as the Spa of the Hotel Le Bristol Paris, of any responsibilities resulting to present or future disorder or pathology occurring after a massage or a care.

Being conscious that the massage has no therapeutic aim or doesn’t cure any disease or physical accident.

Being aware, beforehand, of the proposed technique of massage.

To have given all the information required about my health before the massage or care.

Dear guests, lockers are available for you to store your personal belongings. The Hotel Management declines all responsibility as far as concerns loss, theft or damage to the items.

For our staff only - A remplir par le praticien(ne)

Massage oil preference:

Temperature of the room:

Type of music:

Comments:

Signature *

Please sign in the box above

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