775497991
Reflexology Client Consultation Form (Reproductive)

All information provided in this document is treated in strictest confidence and will not be divulged to any other practitioner, without your permission.

Are You:
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Contraindications Caution Check
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Any Fertility Difficulties?
Previous Treatment(s)
Do you or have you suffered from any of the following? (Please tick any that apply either currently or previously)
Have you been checked or previously treated for:
Contraception:
Are you currently taking any of the following? (Please tick any that apply)
Upload File(s)
Max File Size 15MB
Any Fertility Difficulties?
Have you had a semen analysis?
Upload File
Max File Size 15MB
Have you had any of the following?
Have you been checked or previously treated for:
Are you currently taking any of the following? (Please tick any that apply)

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