Treatment Consultation Form

To help prevent the spread of COVID-19 in the clinic and local community, we ask each client to complete and sign this form before attending for treatment.

On review of the form, your practitioner may contact you to ask you not to attend for your treatment at this time and will discuss a suitable future appointment.

N.B. Every question must be answered.
We have taken extra measures to safeguard our patients prior to arrival. We kindly ask you to complete this
declaration for the safety of you, our patients and therapists.

Reflexology is a holistic therapy. Through the application of steady, even pressure using specific thumb and finger techniques, reflexology connects with the peripheral nervous system and encourages the body to relax.  Each reflex point on the Feet, Face and Hands connects with a specific organ, gland, body part, or body system. The treatment reduces stress and increases your health and wellbeing.


Personal Information

Lifestyle Information

Medical History

Are you happy for me to securely store your Consultation Form ? The information will be held in the strictest of confidence and will not be shared with any third party unless explicit permission has been given by you to do so.  We respect your rights under GDPR.
For security verification, please enter any random two digit number. For example: 43
If you can draw signature that would be good. Initials will do too !