Consultation form

First name

Last name

Email

Phone

Birthday

Day

Month

Year

Are you currently receiving medical treatment or under a GP / consultant?

Yes

No

Please list any medical conditions

Are you taking any medication? (prescribed or over the counter)

Do you you have any of the following? Please tick all that apply.

If you are pregnant, how many weeks?

If you answered yes to any of the above please provide details (including dates, severity or treatment if relevant.)

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that reflexology is a complementary therapy and is not a substitute for medical treatment. I agree to inform my practitioner of any changes to my health.

I agree

I give my consent to receive reflexology treatment.

I agree

Signature

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