Client Information:
Your Full Name (*)
[text* your-name]
Cell Phone(*)
[tel* Contactnumber]
Please list areas of tension, stress and/or pain you wish to be addressed (*):
[text text-903]
Please list any areas you prefer NOT to be worked on (*):
[text text-348]
|
– Have you ever had reflexology before? (*): |
[checkbox checkbox-967 use_label_element exclusive “Yes” “No”] |
Health Information:
– Please mark any of the following that you now have or have had (*):
|
[checkbox* checkbox-354 “Neuropathy”]
[checkbox* checkbox-354 “Joint Replacement”] [checkbox* checkbox-354 “Muscle/bone injuries”] [checkbox* checkbox-354 “Pregnancy”] [checkbox* checkbox-354 “N/A”] |
[checkbox* checkbox-354 “Blood clots”]
[checkbox* checkbox-354 “Heart attack”] [checkbox* checkbox-354 “Neck/back/spinal disorder”] [checkbox* checkbox-354 “Sciatica”] [checkbox* checkbox-354 “Other”] |
|
Injuries/accidents/illnesses still affecting you: |
[text text-913] |
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)
[signature* signature-932 cols:500 rows:250 background:#FFFFFF]
Your full name/ Date (MM.DD.YYYY) (*):
[text* text-104]
[submit “Send to US/ Submit”]
All your personal information is kept confidential and will not be shared with anyone outside of Bangkok Reflexology.
1
CLIENT HEALTH INTAKE FORM: “[your-name]” “[Contactnumber]”
[_site_title]
bkreflex2016@gmail.com
CLIENT HEALTH INTAKE FORM:
-Customer Name: [your-name]
-Customer Phone: [Contactnumber]
-Please list areas of tension, stress and/or pain you wish to be addressed: [text-903]
-Please list any areas you prefer NOT to be worked on: [text-348]
-Have you ever had reflexology before?: [checkbox-967]
Health Information:
– Please mark any of the following that you now have or have had: [checkbox-354]
– Injuries/accidents/illnesses still affecting you: [text-913]
– Signature: [signature-932]
– Name/ Date: [text-104]
————-
Bangkok Reflexology (http://bkreflex.com)
Reply-To: bkreflex2016@gmail.com
[_site_title] “[your-subject]”
[_site_title]
[your-email]
Message Body:
[your-message]
—
This e-mail was sent from a contact form on [_site_title] ([_site_url])
Reply-To: [_site_admin_email]
Thank you for your message. It has been sent.
There was an error trying to send your message. Please try again later.
One or more fields have an error. Please check and try again.
There was an error trying to send your message. Please try again later.
You must accept the terms and conditions before sending your message.
The field is required.
The field is too long.
The field is too short.
The date format is incorrect.
The date is before the earliest one allowed.
The date is after the latest one allowed.
There was an unknown error uploading the file.
You are not allowed to upload files of this type.
The file is too big.
There was an error uploading the file.
The number format is invalid.
The number is smaller than the minimum allowed.
The number is larger than the maximum allowed.
The answer to the quiz is incorrect.
The e-mail address entered is invalid.
The URL is invalid.
The telephone number is invalid.