Soulstice Consultation Form
Client Name
First Name
Last Name
Phone Number
*
Please enter your mobile number omitting the 0
Email Address
*
example@example.com
Have you had Facials, Reflexology before?
Yes
No
Are you / have you experienced any of the following?
*
Pre - Menopause
Vaginal Atrophy
Peri - Menopause
Tiredness
Menopause
Brain Fog
Post - Menopause
Body Regulation
Rather not say
Hair Loss
Other
Check the following if any of them applies for you.
Pregnancy
Breast feeding
Cancer Treatments
Pace Maker
High Blood Pressure
Low Blood Pressure
Heart Condition
Neurological Concerns
NA
Are you taking any medication?
*
Yes
No
Please give details.
*
What would you like to achieve from todays Treatment / Experience?
*
An example might be - Relaxation
Select your skin type and concerns:
Normal
Dry
Balanced
Oily
High color
Sensitive
Sun damage
Wrinkles
Dark circles
Other
Date
-
Day
-
Month
Year
Date
Client's Signature
Therapist Name
First Name
Last Name
Therapist's Signature
Save
Submit
Submit
Should be Empty: