Consultation Form

Dear Guest,

________ Spa considers your health, safety and comfort of the utmost importance. In order to
make your visit to our spa a memorable and increase your comfort and pleasure please kindly
answer the following questions:

1. Have you undergone any medical operation during the past year? ____Yes ____ No
If yes, please provide a brief history _______________________________________
____________________________________________________________________
In case of a recent operation, has your medical doctor certified that it is safe for you to
undergo spa treatments? _____ Yes _____ No

2. Do you suffer from any health condition such as high blood pressure, heart problems
or other illnesses? _____ Yes ____ No
If yes, please describe the nature of your illness _____________________________
____________________________________________________________________
In any of the above cases, has your medical doctor certified that it is safe for you to
undergo spa treatments? _____ Yes _____ No

3. Do you suffer from any allergy or skin sensitivity? _____ Yes _____ No
If yes, please state the type of products/ingredients you are allergic to ____________
____________________________________________________________________
Dara Pirom Spa utilizes only the best quality spa products usually made from natural
ingredients. We will strive to avoid using products with ingredients that you are allergic
to.

4. Question applies to Female guests only

Are you pregnant? _____ Yes _____ No

If yes, please indicate the stage of pregnancy _______________________________
Please note that it is not advisable for pregnant guests to have Spa treatments
with the exception of selected beauty treatments such as manicure, pedicure,
hair treatment and facials.

5. Dara Pirom Spa recommends that you place your valuables in your room safe as we
decline any responsibility for these items.

6. Most of our treatments are best enjoyed without clothing, however if you prefer not to,
kindly request for disposable undergarments from the spa therapist.

Disclaimer:

_______ Spa is in compliance with all pertinent government regulations of the Kingdom of
Thailand and acts in good faith. The customer accepts full responsibility for their visit to
_______ Spa and waives all legal responsibilities of __________ Spa, its owners, staff and
representatives.

Date: Guest signature: