Reflexology Intake Form
Name
First Name
Last Name
Age
Gender
Male
Female
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Phone No. of Emergency Person
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Company Name
Select an appointment
Reason for visit
Is this your first time having a massage?
Yes
No
Do you have any allergies?
Yes
No
Please indicate the irritants or allergens that trigger your allergies
Are you currently taking any medications?
Yes
No
Please list below the medications you're currently taking.
Rows
Medication Name
Purpose
Frequency
1
2
3
4
Are you pregnant?
Yes
No
Did you undergo any surgical procedure in the past?
Yes
No
If yes, what is the procedure name and what is your medical condition at that time?
Kindly check if you have any of the following medical condition
Arthritis
Joint Pain
Cardiovascular disease
Carpal Tunnel
Autoimmune diseases
Epilepsy
Sciatic Nerve
Headaches
Other
What are the areas or location you don't want the therapist to touch?
Agreement
I authorized this center to perform this treatment or therapy for me.
I understand that this procedure is considered an alternative therapy and the resulting output is not one hundred percent.
I hereby hold harmless this center and its employees including the therapist from any liabilities, accidents, or damage that might happen during the procedure.
I confirm that all information in this form is accurate and true to the best of my knowledge.
Signature
Date Signed
 -
Month
 -
Day
Year
Date
Submit
Should be Empty: