Suzanne's Foot Reflexology Care

HEALTH HISTORY FORM

An accurate health history is important to ensure that it is safe for you to receive a Foot, Facial Reflexology, Indian Head massage, Therapeutic Touch and Emotion Code. All information gathered for treatments mentioned above is confidential except as required by law. Written authorization will be required for release of any information.

Please indicate conditions you are currently experiencing or have experienced in the past.

Other Infections

Foot Condition

I have read the above information and have stated all my previous and current medical conditions. I take it upon myself to update the therapist regarding any changes in my condition. I understand that all Foot reflexology, Facial reflexology, Indian Head Massage, Therapeutic Touch or Reiki will be discussed and planned with the therapist and will require informed consent. I understand the 24 hrs cancellation policy and agree to pay the missed appointments within 24 hours of my appointment time.

If having trouble with the form above, you can download and email to suzanne@reflexologycare.com
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