Consultation Form

IMPORTANT: Please fill out the registration form here at LEAST 24 hours before your appointment so that I can make an evaluation & assess contraindications if need be.  Your appointment will not be confirmed unless I receive this beforehand.

Personal Information

Emergency Contact

Doctor's Contact

Health Information

Are you currently pregnant or breastfeeding?
Have you ever/do you currently have any of the following conditions?
How do you rate your sleep? (1 being worst and 5 being best)
How do you rate stess levels? (1 being worst and 5 being best)
Frequency of any pain or concern - please select the most accurate

Covid 19 Declaration:

Have your or anyone in your household shown any symptoms in the last 2 weeks of Covid-19?  (This is defined by a new continuous cough, a high temperature, a loss or change in your normal sense of taste or smell)

Have you or anyone in your household or bubble been abroad in the past 2 weeks? 

Are you, or anyone you live with, defined as a high risk or moderate risk of getting Coronavirus? 

(to see a full list of conditions these include, please click: 

https;//www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/)

If you have answered yes to high risk, do you have your doctor’s consent to go ahead with a treatment?

Client Agreement:

I understand Calm Soles do not diagnose illness and acknowledge that holistic therapies are not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive reflexology treatments as a form of therapy.

I also understand that at any time I feel pain or discomfort during the session, I will inform Jeanette immediately so that treatment can be adjusted appropriately.

I have stated my current medical conditions, and will update any changes in my health status.

By my electronic signature below, I agree to the reflexology policy and client agreement above. 

Contact me

Tel: 07766 721 221

Email: jeanettehughes@calmsoles.com

Calm Soles

Located at rear of hairdressers - 

Access via Shrewsbury Road,

Rooney Ponton,

Banks Road,

West Kirby,

Wirral,

UK

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