Name Contact Information Name * DOB * Address * Why have you decided to try Facial Reflexology? * Are you doing any other therapy treatments or under a physician’s care? * Yes No If yes, please list Are you currently taking any medication? * Yes No Do you use medication for pain? * Yes No Are you taking any alternative or natural remedies? * Yes No 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
