Reflexology Treatment

Thank you for taking the time to fill out this form for the upcoming treatment. We’re looking forward to providing you with the ultimate spa experience.  All of the information provided is confidential and will only be shared with the spa party coordinator and the technician performing your service. Your privacy and safety is our utmost concern. Please feel to contact us if you have any questions. 

Client Intake Form

  • Client Information

  • Date Format: MM slash DD slash YYYY
  • Medical Information

  • Reflexology Treatment

  • Because a reflexologist should be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the reflexologist updated on my physical health. My digital signature gives consent for the session and acknowledges that reflexology is not a substitute for medical examination or treatment. It is recommended that I see a physician for any physical ailment that I might have. I understand that the reflexologist does not diagnose, prescribe, treat, nor cure any illness, disease, or other physical or mental disorder. Likewise the reflexologist does not prescribe medical treatment or pharmaceuticals, nor do they perform spinal adjustments. By signing this form, I waive any and all claims, damages, action and liabilities against Synergy Skin Care & Spa arising out of or relating to reflexology, hand/foot treatments, and allergic reactions to services performed. In the event a dispute arises over the outcome of my procedure, I consent solely to arbitration as a legal means of settlement. I understand English, or if I do not, I have appointed someone to translate this consent form in its entirety. I am eighteen years of age (18) or older. My digital signature indicates my consent for the reflexologist and selected associates to contact me via mail, email, and phone.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.