Reflexology Assessment & Consent Form

My focus is on your ability to be healthy. My aim is first to address the issues that brought you here and second to restore a positive, dynamic balance to your whole being and to bring about healing with your own energy. Name: Address: City: Province/State: Country: Postal/Zip Code: Home Phone: Cell Phone: Personal email address: Birth Date (dd/mm/yy): Gender:male female Are you currently pregnant/trying to conceive? yes no Work phone: Emergency contact: Emergency telephone: Emergency cell phone: Please indicate if you have ever had any of the following conditions: high / low blood pressure yes fatigue yes heart-related conditions yes diabetes yes insomnia yes depression yes tension yes arthritis yes sinus problems yes bowel / stomach problems yes back / neck problems yes menstrual problems yes epilepsy yes cancer yes HIV yes headaches / migraines yes circulatory problems yes any surgery both past & recently yes Please list any allergies: Please list all medications you are currently taking: Please list any other condition that I should be aware of: Were you referred by someone?yes no If yes, please give us their name & phone # so we may thank them: Reflexology Consent Waiver: As a professional reflexologist, Jeni Shaw does not make any claims of replacing any medical healing. Therapy is of a complimentary nature only and is taken at the recipient’s own risk. All medical conditions have been disclosed and all contra indications have been clearly discussed. By including my name and checking "yes" to the "I consent" option below, I acknowledge that I have read and understand all parts of this waiver and that I have had the opportunity to ask questions with regard to the described therapy. Name: Date (dd/mm/yy): I consent:yes no

 

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