Health Declaration/Reflexology

Please complete this form at least 24 hours prior to your TCM Reflexology or Facial Reflexology/Zone Face Lift appointment.

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
Have you had Botox, a Face Lift or a Facial Fillers within the past 4 weeks?
Do you have Allergies to anly nut based products or essential oils?
Do you currently have any open sores on feet or face or extreme acne on face?
Are you currently pregnant?

Thanks for submitting!