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
Covid 19 Declaration:
Have your or anyone in your household shown any symptoms in the last 2 weeks of Covid-19? (As defined by latest government guidelines)
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:
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.
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