The information on this form is held in the strictest confidence.  It does not replace your in-depth pre-treatment consultation with me, but it enables me to ascertain whether we can go ahead with a treatment, and if so where to focus.

Reflexology Booking form

Name:
Name
Email:
Email
Phone/mobile
Preferred method of contact
Email
Phone call
Text
Description (click to edit)
I am currently experiencing
Contagious skin disorders/diseases
Cancer/treatment for cancer
Nervous system disease
Severe high/low blood pressure
Recent haemorrhage
DVT
Recent (last 3 months) operations or injuries
Undiagnosed lumps/bumps/swellings
First trimester of pregnancy
skeletal fractures/disease
Major illness/infectious disease
This information is held in the strictest of confidence, and helps me ascertain any contra-indications to treatment, and expedites the consultation period, so I can focus my attention where it is most needed.
I am/sometimes experience:
Name (click to edit)
skin disorders/conditions
high/low blood pressure
recent scar tissue
asthma
product allergies
migraines
Epilepsy
Diabetes type 1
Cut/abrasions/bruises/swellings
pregnancy 2nd and 3rd trimester
This additional information is also helpful
List any medication you take regularly
Description (click to edit)
are you currently under medical supervision?
Description (click to edit)
History of previous holistic treatments
Description (click to edit)
Physical/emotional Reactions/thoughts about previous reflexology treatments
Description (click to edit)
General health, stress levels,
Description (click to edit)
Areas of concern for me to focus treatment on. Tension/Stress/Injuries/Aches and Pains/Energy Levels
Description (click to edit)
Enter the code below in here: