New Client Information

First Name

Last Name

Are you pregnant?

No Yes

Thanks for letting me know. It's not a good idea for you to have reflexology or massage in your first trimester. I'd love to see you when you are over 13 weeks 🙂 If you are in your third trimester, please check with your midwife before booking.

Do you have blood clots, or a history or blood clots?

No Yes

Thanks for letting me know. Please check with your medical team before booking an appointment.

I would like to receive email updates from The Relaxation Room.

Yes No

Your cell phone number?

I will not have had vaccinations within 48 hours prior to my treatment:

Agree Disagree

I am booking in for:

Reflexology Relaxation Massage (only available in Tokomaru) Reflexology/Relaxation Massage Combo (only available in Tokomaru)

Are you presently receiving treatment for cancer?

No Yes I'm receiving care aimed at comfort and quality of life.

Are you receiving chemotherapy? (including oral chemotherapy)

Yes No

Are you looking for support concerning menopause or menstruation symptoms?

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

If other, please tell me what you're experiencing.

Please let me know if you have any of the following:

Any inflammation due to injury e.g. sprained ankle A skin condition that is carried through the blood e.g. boils Varicose veins None of the above

Do you experience pain or discomfort in any part of your body?

Yes No

Please briefly describe your pain/discomfort.

What are the most common reasons for you to visit a doctor or practice nurse?

High or low blood pressure / angina / heart attack / stroke / blood clots muscle - bone - ligament injury / arthritis / surgery / fibromyalgia Skin conditions / allergies Anxiety / depression / insomnia / parkinson's / neuropathy / numbness Other I very rarely go to the doctor.

If other, please tell me what you're experiencing.

Are you currently taking any medications or nutritional supplements?

Yes No

What is the reason for taking this medication/supplement? (Just a brief explanation is fine.)

What surgeries or procedures have you had? (Just a brief outline is fine.)

How do you know when you (or your body) are under stress?

Please read and agree to the following:

The information I have provided 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 the future.

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.

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.

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.

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.

Further Information:

Contact: