CONSULTATION CARD

MEMBER NO : ____________
ROOM NO: ______________
NAME-
SURNAME :______________________________________________________
:___________________________
E-MAIL : _____________________@ _______________________
ADDRESS :______________________________________________________
______________________________________________________
PHONE
NUMBER : +90 (______) ______________________________
IDENTITY
NUMBER :___________________________
NATIONALITY :___________________________
BLOOD TYPE : _____Rh ____

PERSONNEL INFOS
ALLERGY AGAINST TO ANY MATERIAL YES NO PREGNANCY YES NO

IODINE ALLERGY YES NO OPERATION ( LAST 6 MONTHS ) YES NO

THYROID DISEASE YES NO MEDICATION YES NO

DIABETES YES NO ALCOHOL YES NO

ASTHMA YES NO TOXICOMANIA YES NO

HEART DISEASE YES NO CIGARETTE YES NO

TENSION DISEASE YES NO ANY METAL IN BODY YES NO

LIVER DISEASE YES NO EPILEPSY YES NO

GENETIC PROBLEMS YES NO COMMUNICABLE DISEASE YES NO

VARIX YES NO HEPATITIS B-C YES NO

SKIN-DERM PROBLEMS YES NO FUNGUS YES NO

EYE DISEASE ( LENS ) YES NO ECZEMA YES NO

SLIPPED DISC YES NO OTHER

CERVICAL DISCAL HERNIA YES NO ANY OTHER HEALTH PROBLEMS

COFFEE/TEA USAGE ___________________________________________________________________

NUTRITION STYLE ___________________________________________________________________

DAILY DRANK WATER ___________________________________________________________________

SKIN TYPE DRY MATURE ACNE OILY SENSITIVE NORMAL MIXED

SKIN CHARACTERISTIC SPOILS MOIST ELASTIC WRINKLES MLA

THICK SPOTS DESQUAMATION STRECHING PIGMENTATION

REGULAR SKIN CARE YES NO ____________________________________________________________

PREFERRED PRODUCTS __________________________________________________________________________________

REGULAR SPORT YES NO SOMETIMES______________________________________________

REMINDING
* IT IS DANGEROUS TO HAVE THERMAL POOL AND MASSAGE AND THERAPY AND TO USE HAMMAM AND SAUNA AND STEEM ROOM AFTER THE MEAL AND ALCOHOL.
SO IT IS IMPORTANTLY SUGGESTED NOT TO HAVE ALCOHOL AND MEAL AT LEAST ONE HOUR AGO BEFORE SPA USAGE.
* IT IS ESSENTIAL TO WEAR SHORTS AND DISPOSABLE UNDERWEARS GIVEN BY THERMAL & CURE CENTRE STAFFS BEFORE THE THERMAL & CURE CENTRE USAGE.
* IT IS SUGGESTED NOT TO KEEP YOUR VALUABLE AND SPECIAL THINGS WITH YOU. IF YOU HAVE TO , PLEASE KEEP THEM
IN YOUR OWN LOCKED CABINES IN THERMAL & CURE CENTRE CHANGING ROOMS. OTHERWISE, OUR HOTEL WILL NOT BE RESPONSIBLE FOR
LOST AND STOLEN THINGS.

I DECLARE THAT THE ABOVE INFORMATIONS GIVEN BY ME, ARE TRUE. I ACCEPT THAT I WILL BE RESPONSIBLE IF ANY PROBLEMS
OCCUR.
DATE:
CUSTOMER
NAME-SURNAME: