Confidential Health History Form
Date of birth:
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In Case of Emergency Contact:
Relationship & Phone:
How did you hear about us?
Hours per week:
On a scale of 0 (none) to 10 (unmanageable), how stressful is your:
Payment – we accept cash, checks, and all major credit cards. Returned checks will incur a $30
charge payable to The Barefoot Dragonfly within 10 business days. Payment is due at time of
Cancellations – we value your business and make a commitment to you to guarantee your
appointment time and refuse all other requests once you have made the appointment. A 24
hour cancellation notice is required for any scheduled appointment. You may be charged up to
the full amount of the session booked if notice is not given 24 hours in advance. Missed or no-
show appointments will be charged the full amount of the treatment booked. Gift certificates
are forfeited and marked redeemed with less than 24 hours cancellation notice, or for a missed
or no-show appointment.
Policies: Please initial that you have read the above policies: _____________________
The Barefoot Dragonfly•11673 Jollyville Rd, Suite 201 • Austin, TX • 78759 • 512-666-9374 •