La Cigale | Mobile Spa | Bringing the spa experience to you

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Your Details
First Name
Surname
E-Mail
Phone
Mobile
Address
Date Of Birth	Choose Date
Doctor's Name
How did you hear about us?
If 'Other' please specify
Treatment Related Information
What pressure of Massage do you prefer? LightMediumHard
Do you suffer medically from any of the following?
Allergies Back ProblemsHeart Condition High/Low Blood PressureEczemaCancer IBSArthritisClaustrophobia Iodine AllergyAsthmaEpilepsy PsoriasisHormone imbalanceHysterectomy Varicose VeinsDiabetesOthers
Are you going through any of the following?
DepressionMenopausePMT Headaches / MigranesPregnancyBreast feeding
Medical History
Are you on any medication or under medical supervision? YesNo
Do you take any supplements? YesNo
Is there a history of family illnesses? YesNo
Have you had any accidents, injuries or recent surgery? YesNo
What is the main purpose of your visit?

Skin type and concerns
NormalDry Combination OilyAcneSensitive Extra SensitiveSun damageLines / wrinkles High colourPigmentationDark Circles / Puffiness Other (please specify)
If Other, please specify
Your Lifestyle
What is your quality of sleep? DeepLightDisturbed
What is you current work status? WorkingHome-basedRetired
What Hours do you work? Part timeShift workFull time
How do you travel to work? WalkPublic TransportCarHome-based
How often do you exercise? NeverDailyWeekly
Do you smoke? No1-20 per day20+ per day
Do you wear contact lenses? YesNo
Your Diet
How would you describe your diet? BalancedModerateOn-the-runPoor
How many units do you drink per day?
Water Fresh Juice Alcohol Coffee Tea
Are you a vegetarian? YesNo
What is your current skin care routine?
CleanseToneScrub SerumDay creamNight cream MaskEye careLip care Neck careSun protection
Body Concerns
Dry SkinCelluliteOverweight Poor CirculationAches and PainsVaricose Veins Others
If 'Others', please specify
What is your current Body care routine?
CleanseScrubMoisturiseSpecific Treatments

I hereby confirm that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatments. I agree that La Cigale will not be held responsible for any loss or damage to my personal property, or injury to myself, howsoever caused. I understand that La Cigale reserves the right of admission at all times during the treatment and hospitality process. I understand that La Cigale is a professional institution and will not allow any indecent behaviour. La Cigale will not be held responsible for any accident, death or other.

Mobile Spa

Bringing the Spa Experience to you

We bring the spa experience to the venue of your choice (home or office) or at Venues without Spa facilities. We also set up at Maropeng, Valley View Guest House, Budmarsh Lodge and De Hoek Country Hotel.