Sedona Mobile ReflexologyIntake Form

SedonaMobileReflexology.com

Client Expectations1. We provide our clients with a competent and professional session which is customized and focuses on the indifidual needs of each client.

2. The client will remain dressed, with only the feet up to the knees or hands up to the elbows exposed.

3. Clients are treated with respect and dignity.

4. Personal and professional boundaries are respected at all times.

5. We treat all clients equally regardless of their age, gender, race, national origin, sexual orientation, religion, sociio-economic status, body type, and plitical affiliation, state of health or personal habits.

6. The reflexologist performs services which he/she is able and qualified, both physically and emotionally, to perform.

7. Appointments are confirmed the day prior to the scheduled appointment and insurance billing is not provided.

Client AcknowledgmentI have read, fully understand and will abide by the reflexology policies and guidelines included herein.

Client Printed Name

Client Signature Date

Circle any specific areas you would likethe reflexologist to concentrate on during the session.

Sedona Mobile ReflexologyIntake Form

SedonaMobileReflexology.com

Personal Information

Medical History

Name Phone Cell

Address

City/State/Zip

Email Date of Birth Occupation

Emergency Contact Phone

The following information will be used to help plan safe and effective reflexology sessions. Please answer the questions to the best of your knowledge.

1. Date of Initial Visit

2. Do you have any sensitivities to scents, fragrances of specific products?

3. Do you bruise easily?

4. Is there a particular area of the body where you are experiencing tension, stiffness, pain or other discomfort? If yes, please identify:

5. Do you have any particular goals in mind for this reflexology session? If yes, please explain:

In order to plan a reflexology session that is safe and effective, I need some general information about your medical history.

6. Are you currently under medical supervision? If yes, explain:

7. Do you see a chiropractor? If yes, how often?

yes no

yes no

yes no

yes no

Sedona Mobile ReflexologyIntake Form

SedonaMobileReflexology.com

Medical History Continued8. Are you currently taking any medications? If yes, please list:

9. Please check any condition listed below that applies to you:

contagious skin condition open sores or wounds easy bruisingrecent accident or injury recent fracture recent surguryartificial joint sprains/strains current feverswollen glands allergies/sesitivity heart conditionhigh or low blood pressure circulatory disorder varicose veinsatherosclerosis phlebitis deep vein thrombosis/ blood clotsjoint disorder rheumatoid arthritis osteoarthritis/tendonitisosteoporosis epilepsy headaches/migrainescancer diabetes decreased sensationback/neck problems Fibromyalgia TMJ carpal tunnel syndrome tennis elbow pregnancy - if yes how many months?

Please explain any condition that you have marked above:

10.Are there any other concerns?

Draping will be used during the session - only the area being worked on will be uncovered. Clients under the age of 17 must be accompanied by a parent or legal gaurdian during the entire session. Informed written consent must be provided by parent or legal gaurdian for any client under the age of 17.

I, (print name) understand that the reflexology I recieve is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the reflexologist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that reflexology should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that reflexologists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because reflexology should not be performed under certain medical conditions, I affirmthat I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the reflexologist updated as to any changes in my medical profile and understand that there shalll be no liability on the reflexologist’s part should I fail to do so.

Signature of client: Date:

Signature of reflexologist: Date:

yes no

Sedona Mobile ReflexologyIntake Form

SedonaMobileReflexology.com

Reflexology Cancellation PolicyLife sometimes gets in the way of keeping an appointment. If you need to cancel your reflexology session, you may do so any time within 24 hours of your time at no charge. If you call to cancel your session and your reflexologist is already en route, a customary 20% fee will be billed. Emergency cancellations are determined at the practitioner’s discretion.

A session will not be conducted if the client is intoxicated, using drugs, or threatening the safety of the reflexologist therapist, the safety of others in the building, or themselves.

Reflexology Guidelines1. If a client has a cold, flu, sore throat, stomach virus, poison ivy, skin rash, or any other contagious condition, we ask that you please reschedule your appointment.

2. Clients must be present and not under the influence of alchohol or drugs.

3. Clients must provide a health history and related helalth update, as deemed necessary.

4. Clients are expected to be clean, having showered and bathed their feet the same day as their session.

5. Clients are asked not to eat a heavy meal less than two hours prior to the reflexology session.

A Note From ElkeThank you for choosing Sedona Mobile Reflexology for your hand and foot reflexology needs. Our goal isto help you achieve the ballance you need for a wholesome, ballanced & vibrant life. We look forward to serving you wherever you may be in the whole Verde Valley! Sedona Mobile Reflexology is proud to be yourmobile reflexology provider!

Very best regards,

Elke Schrie�r