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Reflexology
Returning Reflexology Client
Sole to Soul Ritual
Pregnancy Massage
Reflexology 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.
*
Diabetes
Circulatory disorders
High or low blood pressure
Are you pregnant or trying to conceive
Cancer (current or past)
Do you have any allergies or sensitivities
Epilepsy
None of the above
Recent surgery or injury
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
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
*
Submit
Returning Reflexology Client Consultation Form
First name
*
Last name
*
Email
*
Phone
*
Date of birth
*
Day
Month
Year
Any changes to your health or medical conditions since your last treatment with me?
*
No still the same
Yes, please give further information below
Please list any changes here
Is there anything else you want to make me aware of before your reflexology treatment?
*
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
*
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
*
Submit
Sole to Soul Ritual 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 new medication? (prescribed or over the counter)
Do you you have any of the following? Please tick all that apply.
*
Diabetes
Circulatory disorders
High or low blood pressure
Are you pregnant or trying to conceive
Cancer (current or past)
Do you have any allergies or sensitivities
Epilepsy
None of the above
Recent surgery or injury
If you are pregnant, how many weeks? (Reflexology is not available before 13 weeks)
If pregnant, do you have consent from your GP or midwife to receive treatment?
I have consent
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 and I understand that massage and reflexology are complementary therapies, 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 massage and/or reflexology treatment.
*
I agree
Signature
Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.
Date
*
Submit
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