Kind words about my treatments

Client Information Form

Please complete the form below before attending your first treatment.
(Once submitted this information is not retained online.)

Name *

First Name

Last Name

Email *

Phone Number *

Home Address *

Date of Birth *

Reason for seeking Reflexology

Diagnosed medical conditions *

Please include details of any medications

Health Check

So that I can treat you safely, please tick below if you are affected any of the following:

Acute undiagnosed pain

Allergies

Diabetes

Epilepsy

Osteoporosis

Any cardiovascular condition

Varicose veins/phlebitis

Imminent medical tests or procedures

Recent surgery

Injury to the feet or a foot condition

If you ticked any of the above, please give details:

Describe your sleep pattern

How would you rate your stress levels?

Any other relevant information

Are you pregnant or trying to get pregnant?

Yes. (We will discuss this prior to your first treatment)

Disclaimer *

Please indicate that you understand that reflexology is primarily for relaxation purposes. It is not a replacement for diagnosing or treating medical conditions

Yes, I understand

Thank you! I will be in touch soon.

Sam Palmer is a reflexologist in Stroud, Gloucestershire.
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