Client Health Intake Form

Client Information:

Your Full Name (*)

Cell Phone(*)

Please list areas of tension, stress and/or pain you wish to be addressed (*):

Please list any areas you prefer NOT to be worked on (*):

- Have you ever had reflexology before? (*):

Health Information:

- Please mark any of the following that you now have or have had (*):

Neuropathy

Joint Replacement

Muscle/bone injuries

Pregnancy

N/A

Blood clots

Heart attack

Neck/back/spinal disorder

Sciatica

Other

Injuries/accidents/illnesses still affecting you:

Please read the following information and sign below:

1. I understand that if I experience any unusual discomfort and/or pain during my session it is my responsibility to inform the reflexology technician so that they can adjust the pressure or technique being used.

2. I understand that although reflexology can be very therapeutic, relaxing and reduce muscular tension, it is not a substitute for medical examination, diagnosis and treatment.

3. Some dizziness, soreness, minor bruising, or mild pain may occur after or during a treatment.

4. I have stated all my known physical conditions, and I will keep the reflexology technician updated on any changes.

5. This is a therapeutic health aide and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.

6. I affirm the information on this client form is true and complete and I have read and agree to its contents. Therefore, I agree to indemnify and hold harmless the technicians and Bangkok Reflexology from any and all damages and losses.

SIGNATURE HERE* (Click on clear button to clear Signature)

Your full name/ Date (MM.DD.YYYY) (*):

All your personal information is kept confidential and will not be shared with anyone outside of Bangkok Reflexology.