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Consent Form
Consent to Treat a Minor
Pregnancy Consent Form
Home
Book your session
Services & Prices
Contact & Locations
A Typical Session
About Reflexology
Forms
Consent Form
Consent to Treat a Minor
Pregnancy Consent Form
Walk in, Float out !
Name
*
First Name
Last Name
Email
Mobile number
*
Are you pregnant? If so how many weeks?
*
I am not pregnant
1 Week
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40 Weeks
Are you currently taking any medication?
*
Yes
No
Do you have heart disease or any related problems?
*
Yes
No
Do you have high blood pressure?
*
Yes
No
Do you have arthritis?
*
Yes
No
Do you have respiration difficulties?
*
Yes
No
Do you have any allergies?
*
Do you have any recent or past injuries?
*
Are there any areas in your body causing pain or concern?
I understand the implications of receiving a massage, reflexology or reiki and consent to treatment
*
Yes
I consent to receiving information and offers via email or text
*
Yes
No
Which branch are you visiting today?
*
Northcote Road
Kings Road
Westbourne Grove
Date
*
MM
DD
YYYY
By submitting this form you are agreeing to our terms and conditions (you can find the T&Cs page link at the bottom of our site)
Thank you!
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