Wendy Lewis & Prana Reflexology, LLC - Confidential Client Intake Form

Wendy Lewis & Prana Reflexology, LLC - Confidential Client Intake Form

(All information will be kept strictly confidential, except that which I am legally obliged to report, such as threat of injury to self or others.)
New Client Information

(You may leave any non-applicable items blank unless specified otherwise.)
Name

First NameLast Name
Date of birth (month/day/year): Present age:
Phone Number
Please enter a valid phone number.
Email (for occasional newsletter/special offers)
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact name/number
How did you hear about me? (If personal referral, please give name):
Medical History
How would you rate your present health?

ExcellentGoodFairPoor
Do you smoke?

YesNoOccasionally
Is this your first reflexology session?
If no, when, where & how often were previous sessions?
Main reason for seeking reflexology today:
Please list any past or current illness/injury/surgery in your feet and hands:
Please list any past or current injury/illness/surgery elsewhere in your body. (Please note that reflexologists are not medical intuitives and cannot necessarily "read" this information from your feet):
Are you in any physical pain, either intermittent or constant? Where?
Where do you feel tension most in your body?
Does your work or hobbies involve repetitive hand movements or much time on your feet? (computers,construction, medical, crafting, etc.)? If so, please describe:
Do you have any skin irritations or skin allergies (feet/body)?
Please list any significant current or past physical or mental health issues or hospitalizations:
List any medications you are currently taking, and for what conditions.
Any additional health information you would like to share?

Office Policies
I understand that sometimes unexpected circumstances arise. However, as a solo practitioner with by-appointment-only bookings, last-minute cancellations, reschedulings and no-shows are often a considerable inconvenience.

Every appointment requires numerous preparations. When you schedule a session, you are booking for a service during a particular day/time slot, and I hold that appointment for you.

Missed appointments negatively affect my schedule and the wellness of other clients who would have scheduled at those times.

Appointment Cancellations/Rescheduling

I typically send appointment reminders the day before scheduled appointments. If you are unable to keep an appointment, please call or text at least 24 hours before your appointment, or no later than the night before.

Lateness

Please arrive on time for your appointment. Please allow for possible traffic, etc. If you arrive more than 15 minutes late, your session may have to be shortened to accomodate other appointments after yours. Latenesses of 30 minutes or more are considered no-shows.

No-Shows

You will be charged the full session fee for a no-show, required to be paid in full before you are able to book again.

In short, if you must cancel or reschedule, that is fine, but please do so no later than the night before.

Exceptions to these policies are: extreme weather conditions or dire emergencies, and will be considered on a case-by-case basis. (I will reschedule appointments in the event of extreme weather.)
I have read and understand these policies.*

(Required)

Informed Consent Agreement

(Legal information)
This agreeement contains important information about the professional services and business policies of Wendy Lewis and Prana Reflexology, LLC. When you sign this document, it represents a legally binding agreement between us. By signing, client acknowledges having read and agreeing to all terms of receiving sessions/services from Wendy Lewis. Any questions should be asked prior to receiving treatment. Client also releases Wendy Lewis/Prana Reflexology, LLC from responsibility for any conditions that may arise after receiving services.

Section 1:
I, the client, understand that treatments/services provided by Wendy Lewis/Prana Reflexology, LLC (hereinafter “reflexologist”) are intended to enhance relaxation, decrease stress and improve overall well-being. The terms “reflexology,” “reflexologist,” “sessions” and “services” are purely used for convenience and no other purpose. All treatments/services provided are limited to those for which the reflexologist may lawfully provide.

Section 2:
I hereby consent to session(s) by my reflexologist for the above noted purposes including such assessments and techniques which may be recommended by her.

If I experience any pain or discomfort during the session, I will immediately inform my reflexologist so that the techniques and/or environment may be adjusted to my level of comfort.

Section 3:
I acknowledge that my reflexologist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that the services provided by my reflexologist are not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment or service. I acknowledge that with any treatment or service there can be risks and those risks have been explained to me and I assume those risks.

Section 4:
I have informed my reflexologist of all my known physical conditions, medical conditions, and medications, and I will keep her updated on any changes.

Section 5:
It is understood that any illicit or sexually suggestive remarks or advances will result in the immediate termination of the session, and I will be liable for payment of the full scheduled appointment. Intoxication of any kind will not be tolerated. I will be asked to leave immediately and be charged full price for the treatment session.

Section 6:
Reflexologist or client both reserve the right to end a treatment session at any time for any reason. Client does not need to give any reason for ending a treatment session.

Section 7:
This Contract shall be construed and interpreted in accordance with the substantive laws of the State of Rhode Island, without reference to the principles of conflict of laws of such State. This agreement has been negotiated, prepared and executed in Rhode Island. The parties hereto mandate and agree that any suit, action or proceeding arising out of the agreement shall be submitted first to the Superior Court of Kent County, Rhode Island unless otherwise prohibited by law or equity. All parties acknowledge that they are knowingly submitting to the jurisdiction stated herein regardless of where the contract is executed and performed, and that the terms of this clause have been fairly and fully bargained-for as a necessary part of this agreement.

Section 8:
In the event it becomes necessary for either party hereto to file a lawsuit, arbitration or other proceeding to enforce this Contract or any provision contained herein, the party prevailing in such action shall be entitled to recover, in addition to all other remedies or damages, actual costs and reasonable attorney's fees incurred in such lawsuit, arbitration or other proceeding of competent jurisdiction.

Section 9:
Client agrees to indemnify and save harmless Wendy Lewis, Prana Reflexology, LLC and any agents, employees and assigns against any and all liability, loss, damages, costs and expenses which said Client may hereafter suffer, incur, be put to or pay, by reason of, or having as their origin, claims for personal injuries or property damage, or claims of any kind or nature whatsoever arising out of injuries or damages.

Section 10:
I have read the above noted consent and I have had the opportunity to question the contents and my reflexology session. By signing this form, I consent to receiving reflexology and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my reflexologist from time to time, to deal with my conditions and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
I have read and agree to the above Informed Consent Agreement.*

Clear
Should be Empty:

Wendy Lewis & Prana Reflexology, LLC - Confidential Client Intake Form

New Client Information

Medical History

Office Policies

Informed Consent Agreement