Quiet Reflexology - 341 Westwood Boulevard, Upper Tantallon, NS B3Z 4J9 - 902-403-5102 kim@quietreflexology.com www.quietreflexology.com
As with all complementary therapies, a health history is required to ensure it is safe for you to have Reflexology. 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. If you prefer not to fill out this information online please let me know and we can complete forms in person. Thank you.
​
click calendar icon. click on year, scroll to year you were born then choose month and day
Please review the following information and then sign below.
Reflexology is not recommended if you currently have the following conditions
-
Fever
-
Pregnancy, 1st Trimester
-
Contagious diseases, including Cold or Flu
-
Under the influence of drugs or alcohol
-
Recent Surgery
-
Acute Injury
-
Skin Diseases
-
Cancer
You may still have Reflexology if any of these conditions do not affect the area being worked on (feet and lower legs, or hands and forearms):
-
Varicose veins
-
Undiagnosed lumps or bumps
-
Bruising
-
Cuts
-
Abrasions
-
Sunburn
-
Undiagnosed pain
-
Inflammation, including arthritis
Please get your doctor's approval before having Reflexology if you have any of the following conditions.
-
Cardio-vascular conditions (thrombosis, phlebitis, hypertension, heart conditions, angina)
-
Undiagnosed Oedema
-
Psoriasis or Eczema
-
Uncontrolled High Blood Pressure
-
Osteoporosis
-
If you have a Pacemaker
-
Epilepsy
-
Uncontrolled Diabetes
​
PRIVACY STATEMENT
Privacy of the client’s personal information is important. I am committed to collecting, using, and disclosing personal information responsibly.
PERSONAL INFORMATION
Personal information will be used for Reflexology business purposes only. 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
• With your written permission.
INFORMATION DISCLOSURE
Your personal information shall be disclosed to only those who have a need to know the specific information. Those who have a need to know include other reflexologists and health care providers (i.e. personal physicians, naturopaths, chiropractors, etc.). and will not be disclosed without your written permission.
CONSENT
I, the undersigned, consent to Reflexology sessions and understand that the sessions are for stress reduction and relaxation. Reflexology does not 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.