Dien Chan Zone Face Reflexology Client Consultation and Consent

Due to COVID-19, we are temporarily limiting the number of daily appointments. The health and safety of our clients and staff is very important to us. For this reason, walk-in appointments will not be accepted and clients who are not currently receiving a service will be asked to step out in order to control the number of people within the salon/spa/clinic. If you are experiencing a fever, cough, or sore throat, please reschedule your appointment for when you are no longer symptomatic. If you have been to a COVID-19 impacted area or have been in close contact with a person infected with COVID-19, we ask that you please reschedule your appointment for 14 days past the date of contact. Please note, we are requesting that clients wear face coverings when they arrive for their appointments.

Contact Information

Name

Phone Number

DOB

Email Address

Address

Why have you decided to try Facial Reflexology?

Are you doing any other therapy treatments or under a physician’s care?

Yes

If yes, please list

Are you currently taking any medication?

Yes

Do you use medication for pain?

Yes

Are you taking any alternative or natural remedies?

Yes

If so, what kind?

Any Allergies or intolerances?

Are you dealing with any chronic conditions?

What is your sleep pattern?

What is your stress level, scale of 1-10?

Ladies: What are your menstrual patterns?

Please list anything additional you would like to share about your most pressing condition currently or something of secondary concern :

Dien Chan Zone is a wellness therapy proven to be helpful for many conditions. It does not replace your Doctors care or advice. Please seek advice from your Doctor for any serious concerns or changes.

I give permission to my therapist to perform the treatment we have discussed and will hold her from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known
allergies or prescription drugs or products I am currently ingesting or using topically.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Client Signature

Therapist: Sandra Hicks