Lifestyle Consultation Form | Muckross Park Hotel & Spa

Best Rate Guarantee
No Booking Deposit
Complimentary Spa Access
Failte Ireland Safety Charter Approved

Name*
First Last
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Email*
Telephone*
Date of Birth*
DD slash MM slash YYYY
Occupation*
Where did you hear about our Spa?*
Sign me up for exclusive special offers and updates from the Spa at Muckross.
- Tick this checkbox if you wish to receive.
Please tick if you suffer of any of the following?
- Heart Condition
- Diabetes
- IBS/Constipation
- Headaches/Migraine
- Kidney Problems
- Hand/Foot Problems
- High/Low Blood Pressure
- Allergies/Skin Sensitivity
- Muscular/Joint Problems
- Frequent Coughs/Colds
- Varicose Veins
- Skin Problems
- Epilepsy
- Asthma
- Depression
- Cancer
- Food Allergies
Have you recently had an operation?*
- Yes
- No
If Yes, specify and how long ago
Are you currently taking any medication? Please specify*
Are you currently taking any supplements? Please specify*
Are you using products using Retin A or Alpha Hydoxyl Acid (AHA'S)*
Are you pregnant / recently had a baby?*
- Yes
- No
If yes how far in pregnancy / how long ago
Are you currently lactating?
- Yes
- No
Do you have any metal implants (ie Coil or Pacemaker)?*
- Yes
- No
What would you like to achieve from your treatment?
What are you doing after your treatment?
How are you feeling today? 1-10 low-high Physically / Emotionally
What is your lifestyle like?
Diet Fluid Intake Smoking Sleeping Patterns Preferred Pressure Area to Focus on Exercise Routine Any other comments
Self-Declaration Questionnaire

The safety of guests, employees, and visitors at the Muckross Park Hotel remains our overriding priority.

As the coronavirus disease (Covid-19) outbreak continues to impact on our daily lives, the Muckross Park Hotel are conducting a simple screening questionnaire in order to reduce any potential risk of exposure to our guests’, employees and visitors. We kindly ask you to complete the below in full prior to visiting our Spa at Muckross.
Date of Booking*
DD slash MM slash YYYY
Date Completing Form*
DD slash MM slash YYYY
Please circle Yes or No. If the answer to any of the following questions is Yes, please do note that unfortunately access may be denied to the premises.
Have you returned from abroad from any country including Northern Ireland within the last 14 days?*
- Yes
- No
Have you had close contact with or cared for anyone diagnosed with Covid-19 within the last 14 days?*
- Yes
- No
Have you experienced any cold or flu-like symptoms to include fever, persistent cough, sore throat, respiratory illness or difficulty breathing in the past 14 days?*
- Yes
- No
Check here to indicate that you have read and agree to our Covid19 Spa Guidelines.*
- By clicking the SUBMIT button you agree that the information provided is correct at the time of submission and fully accept that based on the information provided, the spa management may deny your access to services at The Spa at Muckross.
Covid19 Spa Guidelines.
DATA PRIVACY INFORMATION*
- I have read and accept the privacy policy

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Diet	Fluid Intake	Smoking	Sleeping Patterns	Preferred Pressure	Area to Focus on	Exercise Routine	Any other comments

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Self-Declaration Questionnaire