Reflexology Consultation/Consent Form | Beauty Forms Portal

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Reflexology Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical Information

Are you currently taking any medications? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

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Health Information

Are you currently pregnant? *

How far along? *

Any high risk factors? *

Have you ever had any orthopedic injuries? *

Please explain: *

What is your occupation? *

Please indicate if any of the following apply to you and give details below:

Cancer Headaches/migraines Arthritis Diabetes Joint replacement(s) High/Low Blood pressure Neuropathy Fibromyalgia Stroke Heart attack Kidney dysfunction Blood clots Numbness Sprains/strains

If you have ticked any of the above conditions please give details:

Any additional notes/comments regarding your medical history/condition:

Lifestyle

Please rate the following on a scale of 1 (Bad) to 5 (Excellent):

Quality of sleep *

Energy levels *

Stress levels *

Quality of nutrition *

Exercise habits *

Treatment Information

Have you had reflexology before? *

Why are you seeking reflexology today? *

What are your goals for this session? *

Please give details of any areas of discomfort (including which side of the body):

Consent

Please tick to show your understanding and agreement. *

If I experience any pain or discomfort during the session I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that reflexology should not be construed as a substitute for medical examination diagnosis or treatment and that I should see a physician chiropractor or other qualified medical specialist for any mental or physical ailment of which I am aware. Because reflexology should not be performed under certain medical conditions I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so. This is a therapeutic reflexology session and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment. I understand the reflexology practitioner reserves the right to refuse services to me for any reason that she/he deems necessary.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.

Signature: *

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Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to your sense of smell or taste
shortness of breath
feeling tired or exhausted
an aching body
a headache
a sore throat
a blocked or runny nose
loss of appetite
diarrhoea
feeling sick or being sick

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