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Holistic Facials & Paraffin Wax Treatments
Client Consultation Form
Caution Check:
Acute Undiagnosed Pain
Cardiovascular Condition
Allergies
Varicose Veins/Phlebitis
Diabetes
Imminent Medical Tests/Procedures
Epilepsy
Recent Surgery
Osteoporosis
Injury to the Feet or Foot Condition
None of the Above
Have you received your Covid-19 vaccinations?
Yes
No
Was it on time?
Yes
No
What was the flow like:
Light
Medium
Heavy
Are you pregnant or trying to conceive?
Pregnant
TTC
Perimenopause or Menopause
Perimenopause
Menopause
n/a
I am pregnant or trying to conceive. I have discussed the possibility of miscarriage and have been advised by the practitioner that there is no evidence to suggest that having Reflexology can provoke a miscarriage, and I am willing to go ahead with the treatment at my own risk.
I declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive Reflexology and any other therapies as listed above. (You will be presented with a copy of this consultation form, for your signature, at your appointment)
I understand that Reflexologists do not claim to cure, diagnose or prescribe, and that Reflexology should not be used as an alternative to seeking medical advice. Always consult your medical professional/GP.
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Thank you for submitting! I look forward to seeing you soon!
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