Consultation Form

Consultation Form

Please complete this consultation so we can assess suitability and record the legally required information for your chosen service(s).
Client Details
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History and Treatment Suitability
Are you currently pregnant?
Do you have any known allergies or sensitivities?
Which skin conditions apply to you?

Other
Do you have any of the following health conditions?

Other
Have you had any recent operations, injuries, or hospital treatment?
Are you taking any medications or treatments?

Other
Have you had, or been exposed to, any infectious or contagious conditions recently?
Please provide any other medical information relevant to your treatment suitability.
Is there anywhere on your body you would like us to pay particular attention to?
If you notice any knots or tension in an area, would you like the therapist to work on it to help relieve it?
What pressure would you prefer?
Would you prefer a quiet appointment?
Consent and Declarations
Data protection and privacy agreement
Signature
Reflexology Intake
What are your current stress levels from 1-10?
What is your occupation?
If your current stress levels are high, do you know the source of the stress?
Any pain or issues with foot health?
What is your water intake, how many glasses per day?
Should be Empty:

Consultation Form

Client Details

Medical History and Treatment Suitability

Consent and Declarations

Reflexology Intake