Your information also allows us to provide you with Reflexology sessions that will be of the greatest benefit to you. Your written consent to have Reflexology is required prior to the start of your session. If you are at all unsure that it is safe for you to have Reflexology, please consult your physician.
All information provided by you is voluntary and confidential.
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Please review the following information and then sign below.
REFLEXOLOGY IS NOT RECOMMENDED IF YOU HAVE THE FOLLOWING CONDITIONS:
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Fever
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Pregnancy, 1st Trimester
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Contagious diseases, including Cold or Flu
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Under the influence of drugs or alcohol
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Recent Surgery
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Acute Injury
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Skin Diseases
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Cancer
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Recent Injections or treatments such as IVF
REFLEXOLOGY MAY BE PERFORMED ON OTHER AREAS IF YOU ARE EXPERIENCING:
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Varicose veins
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Undiagnosed lumps or bumps
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Bruising
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Cuts
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Abrasions
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Sunburn
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Localized pain
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Inflammation, including arthritis
PLEASE GET YOUR DOCTOR'S APPROVAL PRIOR TO REFLEXOLOGY IF YOU HAVE:
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Cardio-vascular conditions (thrombosis, phlebitis, hypertension, heart conditions, angina)
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Undiagnosed Oedema
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Psoriasis or Eczema
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Uncontrolled High Blood Pressure
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Osteoporosis
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If you have a Pacemaker
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Epilepsy
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Uncontrolled Diabetes​
PERSONAL INFORMATION
Personal information is protected and used only by Quiet Reflexology. This information is:
• The information necessary to provide professional Reflexology services to you.
• The information necessary to administer this Reflexology business.
• Personal information includes all the information that you provided on your client information/health history form at the first visit and any subsequent visits.
• Personal information may also include any information that you provided during the normal course of communication between you and I. I will use and disclose only the information:
• You provided to me
• Or is provided by another person acting on your behalf
• To another practitioner only by your request and with your written permission.
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CONSENT
I, the undersigned, consent to Reflexology sessions and understand that the sessions are for stress reduction and relaxation. Reflexology is not a substitute for medical examination, diagnosis, or treatment, and I will consult a physician or other qualified medical specialist for all my mental or physical ailments of which I am aware. I may stop the session at any time, either during the assessment or the treatment. Reflexology therapists do not diagnose, prescribe, or treat specific conditions. I confirm that I have informed the Reflexologist of my known medical conditions and answered all questions honestly. Should I seek further Reflexology sessions from the Reflexologist, I agree to update them to any changes in my medical profile and understand that there shall be no liability on the Reflexologist’s part should I forget to do so.