Peace Roots Reflexology New Client Form
Email address *
Name *
Address *
Phone number *
Birthday *
Please list issues that bring you to reflexology: *
Please list CURRENT medical conditions *
Please list PAST medical conditions *
Please check all that apply: *
Blood clotting issues past or present (Reflexology improves circulation. If dealing with any clotting issues a Doctor should be consulted)
(Women) Are you pregnant?
Do you have any contagious skin conditions on or around your lower leg/ankle/feet?
Do you have varicose veins?
Are you currently undergoing cancer treatments?
Are you currently under a doctor's care *
IF you are under a doctors care for any preexisting condition, please share:
Are you allergic to latex or any creams, oils or topical salves? *
By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge: *
COVID WAIVER -Peace Roots Reflexology
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Peace Roots Reflexology LLC has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Peace Roots Reflexology LLC can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including staff.
I voluntarily seek services provided by Peace Roots Reflexology LLC and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Peace Roots Reflexology harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Peace Roots Reflexology LLC. I understand that this release discharges Peace Roots Reflexology LLC from any liability or claim that I, my heirs, or any personal representatives may have against the practice with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received from Peace Roots Reflexology LLC. This liability waiver and release extends to the practice together with staff.
By entering your initials in the box below, you are effectively providing your signature, indicating you accept the terms of the above waiver. *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy