Mobile Reflexology
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HEALTH DECLARATION & CONSENT

Please read carefully before completing this form. For safety reasons, certain medical conditions or circumstances may make treatment unsuitable or require modification. Your health and wellbeing are always my highest priority.
PATIENT DETAILS
MEDICAL HISTORY
1. Medical history in the last 12 months
Please include any operations, illnesses, injuries, or infectious diseases:
2. Are you currently receiving treatment from a healthcare professional or GP?
HEALTH CONDITIONS
Please tick any that apply to you:
Are you taking any medications regularly?
CONSENT & AGREEMENT
I confirm that the information I have provided is true, accurate, and complete to the best of my knowledge.

By submitting this form, I agree that:

  1. I will inform the therapist of any changes to my health before each session.
  2. I understand that treatment may be adapted, postponed, or declined if it is not considered safe.
  3. I consent to receiving reflexology treatment and understand it is a complementary therapy, not a substitute for medical treatment.
  4. I will communicate any discomfort during the session.
  5. My personal data and health information will be stored securely and confidentially, in line with UK GDPR requirements.
  6. My records may be retained for up to 5 years for insurance and legal purposes and then securely destroyed.
  7. I understand I can request access to, or deletion of, my personal data at any time.
ONLINE DECLARATION & CONSENT
Date of Submission: January 13, 2026 23:10