0
Our services
Thermal experience and packages
Massages
Aesthetics and facials
Health form, Massage therapy
Aesthetic health form
Schedule and info
Promotions
Shop
Booking
Français
0
was successfully added to your cart.
Cart
Aesthetic health form
Health Form
Beautician Spa La Belle Blanche Annie Duquette
Personal details
Name
*
First name
*
Telephone (residential)
Cell Phone
Gender
Madam
Mister
Date of birth
DD
MM
YYYY
Email
*
Email promotion
Yes
No
Occupation
Address
Address
City
Zip code
Survey
Reason for consultation
What are your expectations regarding treatment?
Are you pregnant ?
Yes
No
Do you take medication
Yes
No
If yes, which ones ?
Do you have allergies ?
Yes
No
If yes, please specify
Have you had one or more surgeries?
Yes
No
If yes, please specify
Do you have metal implants in your body?
Yes
No
If yes, please specify
Do you have a health problem that requires me to know :
Tell me about your skin :
What is your skin care routine :
The purpose of this health questionnaire is to obtain information on your state of health in order to adapt our care to your situation. Although this questionnaire is only for advisory purposes, failure to report information could affect your follow-up. In this case, the professional responsibility of the principal could not be engaged. In this context, it would be useful for you to carefully complete this questionnaire.
*
I have filled out the form
Signature
Date
DD
MM
YYYY
Our services
Thermal experience and packages
Massages
Aesthetics and facials
Health form, Massage therapy
Aesthetic health form
Schedule and info
Promotions
Shop
Booking
Français
