The information on this form is held in the strictest confidence.  It helps me to know whether you have any contra-indications to reflexology treatment, and whether we can go ahead or not. It doesn't replace your in-depth consultation prior to treatment, and means I have more time to focus on areas of concern.

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)
Maternity Reflexology
Name (click to edit)
Check this box if you're pregnant and would like a Maternity Reflexology treatment
Fertility Reflexology
Name (click to edit)
Check this box if you/you and partner would like reflexology support through your Assisted Conception (IVF, ICSI etc) or as a preparation for conception
Enter the code below in here: