Treatment Consultation Form

Reflexology is a holistic therapy. Through the application of steady, even pressure using specific thumb and finger techniques, reflexology connects with the peripheral nervous system and encourages the body to relax.  Each reflex point on the Feet, Face and Hands connects with a specific organ, gland, body part, or body system. The treatment reduces stress and increases your health and wellbeing.

For insurance purposes, if you currently have a medical condition, I would really appreciate it if you could download the enclosed Doctor Consent Form and get it signed by your doctor to confirm that it is OK for you to have a treatment.  Bring it along with you when you come for your appointment 🙏🏽.  Doctor Consent Form

 

PERSONAL INFORMATION

PREGNANCY INFORMATION

Please give details
Please give details
Do you or have you suffered from any of the following ?
Are you happy for me to securely store your Consultation Form ? The information will be held in the strictest of confidence and will not be shared with any third party unless explicit permission has been given by you to do so.  We respect your rights under GDPR.
For security verification, please enter any random two digit number. For example: 84