Reflexology Consultation Form

First name

Last name

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Emergency Contact

Emergency Contact Telephone Number

If 'Other' please provide details

Recent operations or injuries (please specify)

Pregnancy (How many weeks?):

Allergies (please specify)

Cancer (type and treatment):

Skin conditions:

Other medical conditions (please specify)

Are you currently taking any medications

Yes

No

Do you suffer from stress?

Rarely

Occasionally

Frequently

Constantly

Have you had reflexology before?

Yes

No

What are your main reasons for seeking reflexology today?

What level of pressure do you usually prefer during treatments? (Please note there re areas on the foot that will be treated lightly like the digestive system).

Light

Medium

Firm

Consent and Disclaimer

I understand that reflexology is a complementary therapy and is not a substitute for medical treatment. I confirm that the above information is accurate and complete to the best of my knowledge. I give consent to receive reflexology treatment.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date

Day

Month

Year

Welcome to