Confidential Health History Form (Page 5 of 5) in pdf

Informed Consent to Treatment

What is Reflexology? Reflexologists believe the entire body is mirrored on the feet and hands.

Foot and hand reflexology is a scientific art based on the premise that there are zones and reflex

areas in the feet and hands which correspond to all body parts. The physical act of applying

specific pressures using thumb, finger, and hand techniques results in stress reduction which

causes physiological changes in the body. A primary benefit of reflexology is relaxation.

Relaxation through reflexology may help the body to balance any kind of stress it is

experiencing.

Reflexology is not a substitute for medical treatment, but does complement most types of

therapy. Amy Kreydin is not a doctor nor does she practice medicine. She does not diagnose or

treat for a specific illness nor prescribe or adjust medication.

What does Reflexology do?

1. Reflexology promotes balance and normalization of the body naturally;

2. Reflexology reduces stress and brings about relaxation; and

3. Reflexology stimulates circulation and the delivery of oxygen and nutrients to the cells.

By signing this form, I give my consent to a reflexology session. I acknowledge I have read and

understand the information below.

• I understand I may discontinue a session or sessions at any time.

• If I have been diagnosed by a licensed health professional as having any disease, injury or

other physical or mental condition, I understand that I should inform the person who

made the diagnosis, about the sessions I will be receiving, and whether or not I intend to

discontinue any treatment or therapy which had been previously ordered, prescribed or

recommended by a licensed health professional. **I understand that by discontinuing

any such treatment or therapy I agree to hold Amy Kreydin free from any liability,

assuming responsibility for any negative outcome resulting from discontinuing that

treatment or therapy.

• I understand that oils and lotions are used during a reflexology session. **I understand

that by neglecting to inform the Reflexologist of any sensitivity to oils and/or lotions,

before or during session, I agree to hold Amy Kreydin free from any liability, assuming

responsibility for any negative outcome resulting from the use of oils and/or lotions

during a reflexology session.

Client Signature ________________________________________ Date: ___________________

Reflexologist Signature __________________________________________________________

REFLEXOLOGY IS NOT A SUBSTITUTE FOR MEDICAL CARE. IF YOU ARE EXPERIENCING ANY SPECIFIC

MEDICAL PROBLEM AND HAVE NOT SEEN YOUR MEDICAL DOCTOR, I RECOMMEND YOU DO SO TODAY.

Revised from ARCB 2006

Confidential Health History Form Page 5