Reflexology Consultation Form

Client Consultation Form

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityCounty

Post CodeCountry

Birth Date

MonthDayYear

Phone Number

Format: (000) 000-0000.

E-mail

Emergency Contact

Phone Number

Format: (000) 000-0000.

Occupation

Doctors Name and phone number

Health Information

Medications

Allergies

Recent injuries

Are you currently pregnant or breastfeeding?

Please indicate if any of the following apply to you.

How do you rate your sleep?

	1	2	3	4	5

1 is Worst, 5 is Best

Stess levels?

	1	2	3	4	5

1 is Worst, 5 is Best

What would you like to achieve from your appointment? E.g. Relaxation or Specific areas of concern

Frequency of pain or concern - please select the most accurate

Neck

Shoulders

Arms & Hands

Mid-Back

Other

Low Back

Hip

Legs and Feet

What are your favourite aromatherapy oils?

Client Agreement:

I understand that, Sarah does not diagnose illness, disease, any physical or mental disorder, nor does she prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that holistic therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive reflexology treatments as a form of therapy.

I also understand that at any time I feel pain or discomfort during the session, I will immediately inform Sarah so she can adjust the pressure and or treatment.

I have stated my current medical conditions, and will update Sarah of any changes in my health status.

I will notify Sarah of any changes after treatment if necessary.

By my electronic signature below, I agree to the reflexology policy and client agreement above.

I confirm that

Date:

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Date

MonthDayYear