Skip to main content

Client Intake Form

Complete Client Intake Form

  • DD dash MM dash YYYY
  • Reason for Seeking Treatment

  • 's GP

  • Medical Information

  • Lifestyle

  • Other Information

  • I declare the information in this form to be true and accept that it is my responsibility to keep my practitioner updated regarding any changes in my health or medication. I am happy to receive reflexology and any other therapies as listed above.

  • DD dash MM dash YYYY