New Client Form

Disclaimer: Jiao Reflexology is not a medical facility.

Client Information &

Informed Consent Form

First name

Last name

Address (Street Address, City, State and Zip Code)

Phone/Mobile

General Medical Information

Are you currently under medical supervision for any skeletal or muscle condition?

Are you aware of any condition that may cause you pain, discomfort or harm from Reflexology?

Are you currently receiving medical care for any condition that you would exclude reflexology or any of our services?

Informed Consent and Service Acknowledgement

I acknowledge that the Reflexology treatment/Services offered to me is NOT a substitute for any medically performed procedure and that the guidelines within this informed consent are established on my behalf to benefit my health. I hold Jiao Reflexology and its employees harmless from any liability in the procedures and services provided. I understand that submitting this form represents a waiver for subsequent visits to Jiao.

I certify that I am over 18 years old, or I am the client's legal guardian.

I agree to the terms and conditions.

Yes, subscribe me to your newsletter.