Pregnancy Consent Form — Reflexions the Reflexology Shop

Client's Name

First Name

Last Name

I give my consent to have a treatment of either reflexoloy or massage at Reflexions.

My doctor/midwife has not advised me against reflexology or massage during my pregnancy

How many weeks pregnant are you?

Phone number:

I can confirm that I have no medical/health/pregnancy related health issues

Yes

If you do have any medical issues/health issues/pregnancy related issues, please list below. In addition, please list any medication you are taking:

Do you have any allergies (nuts/seeds/citrus/spices/other)?

Yes

If yes, please describe below:

Do you have a history of unstable pregnancy/miscarriage, etc?

Yes

Have you ever had a c-section?

Yes

Are you expecting a natural labour?

Yes

Any other information not already covered which you would like to tell us that may help our therapists give you the best treatment possible?

Disclaimer: By signing below, I approve of and accept full personal liability for myself and for my unborn child in today's session and for any future treatments. I agree to this form and any further session notes being kept on file. I confirm that the above medical information is correct. I have been advised that reflexology is not a substitute for medical treatment and I have been advised to consult with my GP/Midwife. I confirm that the above medical information is correct and agree to update my Reflexions therapist to any medical changes.

Printed Name:

Date:

YYYY

GDRP: We can confirm that this information is confidential and it is not shared with 3rd parties outside of Reflexions or Reflexions therapists. This form and any further notes from your session will be kept in a locked file by Reflexions.

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)