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Meridian Health & Wellbeing
Complementary Health in Kidlington

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New Patient Form - Reflexology

First name*

Last name*

Phone*

Email*

Address*

Date of birth*

Day

Month

Year

Contraindications - that require medical permission

Select if/where appropriate

Pregnancy

Cardiovascular conditions (thrombosis, phlebitis, hypertension, hypotension, heart conditions)

Haemophilia

Any condition already being treated by a GP or another health professional e.g Physiotherapist, Osteopath, Chiropractor, Coach

Medical oedema

Osteoporosis

Arthritis

Anxiety/Stress/Depression

Epilepsy

Recent operations

Diabetes

Asthma

Any dysfunction of the nervous system e.g Multiple sclerosis, Parkinson's disease, Motor neurone disease

Bell's Palsy

Trapped/Pinched Nerve e.g sciatica

Inflamed nerve

Cancer

Cervical Spondylitis

Spinal cord conditions e.g cerebral palsy

Contraindications that restrict treatment

Fever

Contagious or infections disease (fungal/veruca)

Under the influence of recreational drugs or alcohol

Diarrhoea and vomiting

Pregnancy (1st trimester)

Skin diseases

Localised swelling

Inflammation

Varicose veins

Cuts/bruises/abrasions

Scar tissue (2 years for major operation and 6 months for a small scar)

Sunburn

Hormonal implants

Menstruation

Haematoma

Recent fractures (min 3 months)

Disclaimer/Informed Consent

I confirm that I understand the treatment that I am to receive and confirm that I am willing to proceed without confirmation from my own GP or Consultant.

How your information will be used

I take your privacy very seriously; your personal information will only be used for treatment purposes and will never be shared with any third parties, without express permission.

Please note if you do not turn up for your appointment or cancel within 24 hours of the appointment, you will be liable to pay the full fees for the appointment you have missed.

Signature*

Signature field is empty.

From time to time, I would like to get in touch with you when I have information about new therapies and special offers that I think may be of interest to you. If you agree to being contacted in this way, please tick how you are happy to be contacted:

Text

Date*

Day

Month

Year

info@mhw-clinic.co.uk

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