Reflexology Consultation Form

Relax Refresh Reconnect

All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent. It may only be shared with a third party with written consent of the client.

Name

First NameLast Name

Address*

Street Address

Street Address Line 2

CityCounty

Post Code

Phone Number

Area CodePhone Number

Birth Date

E-mail*

Emergency Contact*

Phone Number*

Area CodePhone Number

Occupation

How did you hear about us?

Doctors Name & Phone Number

Medications

Allergies

Recent injuries

PregnantBreastfeeding

How do you rate your sleep?

	1	2	3	4	5

1 is Worst, 5 is Best

How do you rate your energy levels?

	1	2	3	4	5

1 is Worst, 5 is Best

How do you rate your nutrition?

	1	2	3	4	5

1 is Worst, 5 is Best

How do you rate your exercise habits?

	1	2	3	4	5

1 is Worst, 5 is Best

How do you rate your stress 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*

Client Agreement:

By signing, the client agrees to the following:

I give my permission to receive this holistic treatment for relaxation and therapeutic benefits
I understand that reflexology is not a substitute for traditional medical treatments or medications
I understand this is NOT a diagnostic tool and my therapist will NOT diagnose illnesses or injuries and/or prescribe medications
I will immediately inform my therapist if I experience pain or discomfort so my therapist can adjust accordingly
I have clearance from my current physician to receive holistic therapies
I understand the risks associated with reflexology include, but are not limited to:
- Short- term muscle soreness
- Superficial bruising
- Exacerbation of undiscovered injury

I understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the therapist know about any new changes

I understand this session may be terminated at any time by myself or therapist

I have been given a chance to ask any questions or discuss the concerns I may have

By signing this release, I hereby waive and release Relax Refresh Reconnect from all liabilities concerning these injuries that may occur during the treatment session. I have read and understood the information above and consent to the treatment discussed today.

Signature & Date