Skip to content
Home
Treatments
Reflexology
Mobile Reflexology
Massage & Reiki
New Client Form
Gift Certificates
About
Gallery & Feedback
Contact
The Resting Space
About The Resting Space
The Resting Space Accommodation
SHOP
Home
Treatments
Reflexology
Mobile Reflexology
Massage & Reiki
New Client Form
Gift Certificates
About
Gallery & Feedback
Contact
The Resting Space
About The Resting Space
The Resting Space Accommodation
SHOP
New Client Information
Please enable JavaScript in your browser to complete this form.
Your Name (first and last)
*
Are you pregnant?
*
Yes, first trimester
Yes, second or third trimester
No
Thanks for letting me know.
Neither reflexology nor massage is recommended for a person in the first trimester of their pregnancy. I would love to see you when you are in your second or third trimester. All the best with the baby 🙂 - Dee.
Are you presently receiving treatment for Cancer?
*
No
Yes
Yes, I am receiving care aimed at comfort and quality of life.
Thanks for letting me know.
Neither reflexology nor massage is recommended for a person who is currently receiving treatment for Cancer.
Reflexology can be helpful in alleviating some symptoms of cancer and improving over all wellbeing. Please do make an appointment with me when you have cleared it with your medical team - Dee.
Do you have blood clots (or a history of blood clots)?
*
No
Yes
Thanks for letting me know.
Both reflexology and massage encourage increased circulation.
Please check with your health provider that it's ok for you to have reflexology or relaxation massage before making an appointment - thanks, Dee.
Please indicate your age:
*
Under 18 years
18 years to 30 years
31 years to 50 years
50 years to 70 years
over 70 years
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
Relaxation Massage / Reflexology Combo
Are you looking for support concerning menopause or menstruation symtoms?
No
Yes
Where are you at?
I'm perimenopausal (still getting periods)
I'm menopausal (waiting for my 12 months of no periods to finish)
I'm post menopausal (but still experiencing symptoms)
I have Polycystic Ovary Syndrome (PCOS)
I have Endometriosis
I experience disruptive Premenstrual Tension (PMT)
Other
Check any that apply 🙂
Please briefly describe the symptoms that most concern you.
Please let me know if you have any of the following:
*
Inflammation due to injury e.g. sprained ankle
Skin condition that is carried through the blood e.g. boils
Varicose veins
Hernia
History of Cancer
None of the above
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?
*
Head
Neck
Shoulder/s
Arms/wrists
Back - upper, middle or lower.
Hips
Legs, ankles, feet.
None of the above.
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
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
What medication you are currently taking (if any), and the reason for use:
If you can't remember the names, please give me an indication of what your medication is for 🙂
Please let me know what nutritional supplements you are 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:
*
Operations / Surgery
Major Illnesses
Allergies (Intolerances e.g. food, chemical, products ...)
Breathing Issues (e.g. asthma, bronchitis, shortness of breath, emphysema ...)
Discomfort with your Digestive system (e.g. burping, reflux, bloating, bowel issues...)
Headaches, migraines, epilepsy, fatigue...(Nervous System / Brain)
Glandular issues, thyroid, adrenals, diabetes... (Endocrine system)
Menstrual/menopausal issues, pregnancy, miscarriages, fertility... (Reproductive System)
Eczema, psoriasis, itchy, dryness, raw... Integumentary / Skin System
Lymphatic System e.g. oedema/fluid retention in feet or hands...
Urinary System Problems e.g. UTI infections, kidney/bladder issues...
Any other relevant/current medical history or health issues?
None of the above
If you ticked any areas above, please give me a brief description.
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
a the currently
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
Submit
