New Client Information – The Relaxation Room

Your Name (first and last) *

It is not recommended that you have reflexology or massage if: *

You are in the first trimester of pregnancy.
Have blood clots or a history of blood clots
Have Cancer
None of the above.

Please indicate your age: *

Email *

I would like to receive emails updates from the Relaxation Room: *

Yes
No

Your inbox won’t be flooded 🙂 Emails tend to be monthly, or when I have some news I’d like to share.

Your text/cellphone number. *

Emergency phone number *

I’ve never had to use this, but it’s safe practice to have this information.

I will not have had any vaccinations in the 48 hours prior to my appointment. *

Agree

I am booking in for: *

Reflexology
Relaxation Massage and/or Reiki

Please let me know if you have any of the following: *

If you have, we can chat details when you come for your appointment.

Do you experience pain or discomfort in any of the areas below? *

Please tick any that apply.

If you ticked any areas of pain or discomfort, please give me a brief description.

Please indicate if you experience / have experienced any problems or health issues / injuries relating to: *

Breathing / Heart / Blood circulation e.g. high or low blood pressure / angina / heart attack / stroke / blood clots)
Musculo-skeletal e.g. muscle – bone – ligament injury / arthritis / surgery / fibromyalgia
Skin conditions / allergies
Cancer or cancer treatment
Nervous system e.g.anxiety / depression / insomnia / parkinson’s / neuropathy / numbness
None of the above.

If you have, we can chat details when you come for your appointment.

Are you currently receiving any medical/complementary therapy?

Yes
No

Please list medication you are currently taking (if any), and the reason for use:

Please list nutritional supplements you are currently taking (if any).

What is/was the work role you have spent the most time in? *

E.g. Working at a computer, House Painter, Nursing or elder care, student etc.

In the last 5 years have you had any of the following: *

If you ticked any areas above, please give me a brief description.

list of ticked

I have stated all conditions that I am aware of and this information is true and accurate to the best of my knowledge and I have not withheld any information that might affect the course of my treatment. I will inform The Relaxation Room (Dee Hyde) if anything changes in my status. *

Agree

I understand that the treatments provided are to promote stress reduction throughout the entire body, to bring about relaxation, to promote balance and normalisation of the body, and to stimulate circulation and the delivery of oxygen and nutrients to the cells. They are not offered as a substitute for medical care. *

Agree

I understand that Dee Hyde does not diagnose illness or disease, nor perform any spinal manipulations, and does not prescribe any medications or treatments. I acknowledge that treatments provided by The Relaxation Room are not substitutes for a medical examination or diagnosis, and that I should see my health care provider for those services. Services in the Relaxation Room are not claimed to be effective for every ailment, client or specific condition. *

Agree

I understand that I am receiving treatments at my own risk. In the event that I become injured either directly or indirectly as a result, in part or in whole, of the aforesaid treatments, I hereby hold harmless and indemnify Dee Hyde from all claims and liability whatsoever. *

Agree

If I am unable to attend my scheduled appointment, I will respect and abide by the set cancellation policies. Sexual advances, requests for sexual favors, and any other verbal or physical conduct of a sexual nature will be considered sexual harassment and will not be tolerated. *

Agree