Stow-on-the-Wold Reflexology | Pre-Treatment Form

Pre-treatment assessment form

Please complete and send this form before your first appointment. If you are unable to attend your appointment for any reason please contact us asap to rearrange or cancel. Cancellations within a 24 hour period of the treatment time will be charged at half the treatment cost. Cancellations prior to 24 hours notice will incur no cancellation fee.

Name

First Name

Last Name

Preferred Telephone Number

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Reasons for booking treatment?

e.g relaxation, health condition, pregnancy etc

Back/Skeletal problems?

Allergies/Food intolerances or sensitivities?

Heart condition/Blood pressure?

Skin problems?

Digestive system issues?

Insominia /Problems sleeping?

Migraines/Headaches?

Nose/throat/bronchial infections?

Diabetes?

Hormonal/Period Problems?

Tell Me about your diet and exercise

Smoke/Alcohol/Other drugs?

Current stresses?

Family medical history?

Your signature

Today's Date

YYYY

Disclaimer: I understand that any complentary therapy I receive is not a substitute for medical diagnosis or treatment and that I understand it is recommended I see such a practitioner now or in the future.

Agree

Data Protection Act. Your consent is required to store your information and that which is stored must be relevant, accurate and current. Data held by Adrienne Halliday (kSemya) will only be used to contact you in relation to appointments, treatments, newsletters, workshops, groups and special offers. Any contact will be made by phone, email, text or post. Your data will not be passed to any third parties without your permission. Please tick below to those you agree to:

I give my permission to be contacted by phone/text/message

I give my permission to be contact by email

I give my permission to be contacted by post

Pre-treatment assessment form

You are uniquely amazing ♡