Reflexology Client Intake Form

Information you will need

• Do you want to upload the Clinic's logo? af image
• CLINIC ONLY: What’s your name or the name of your clinic?
• CLIENT ONLY: What’s your name?
• What’s your date of birth?
• What's your address?
• What's your home phone number?
• What's your cell phone number?
• What's your email address?
• What's your occupation?
• What's your primary care physician's name?
• Who's your emergency contact?
• What's the emergency contact's phone number?
• Who were you referred by?
• Are you taking any medications?
• What medication are you taking?
• Are you currently pregnant?
• How far along the pregnancy are you?
• Are there any high risk factors with your pregnancy?
• Do you have any allergies or sensitivies?
• What are your allergies or sensitivities?
• Have you had any recent injuries?
• What injuries have you had?
• Do you have cancer?
• Do you experience headaches or migraines?

…and 26 more fields in the PDF.

Completed by the client.

The form includes 1 signature line, a notary acknowledgment.