New Client Intake Form

Client Consent and Agreement

​Privacy of the client's personal information is important. I/We are committed to collecting, using, and disclosing personal information responsibly.

Personal information will be used for Reflexology practice purposes only.

This information is necessary:

• For the provision of professional Reflexology health care services provided to you.

• To administer this Reflexology practice.

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Personal information includes all the information that you provided to us on our client information/health/medical history form at the first visit and any subsequent visits.

Personal information may also include any information that you provided us during the normal course of communication between client and clinic/practice office staff.

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We will use and disclose only the information:

• You provided to us

• Or is provided by another person acting on your behalf

• With your written permission

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I/We are committed to protecting your personal information. We have established Security measures, which have been implemented to properly manage and safeguard your personal information from loss, theft, and unauthorized access.

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• Your personal information shall be disclosed to only those who have a need to know the specific information.

• The specific information disclosed shall be restricted to only that information relevant to the recipient's need to know.

• Those who have a need to know include other Reflexology Therapist and health care providers (i.e personal physicians, naturopaths, chiropractors, etc.)

• Further, the personal information disclosed to Complementary Health Benefit Providers is limited to only the personal information that is required by the provider.

• At any time you may specify: who you do not wish your information to be given to, or give restrictions on  any content disclosuere.

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We will retain your personal information for the period necessary to continue providing services to you, and for its related administration.

We will destroy information in a secure manner when the information is no longer necessary for the provision of reflexology health services and is not required to be retained for compliance with provincial or federal regulations or statutes.

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I/We are committed to providing you with open access to your personal information.

You may at any time ask to see your records held and request amendments to that information.

Access will be provided to you within a reasonable timeframe recognizing your desire for the information and our need to carry on our practice with limited interruption.

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• It is understood that the "I" cited below refers to the client filling and signing this form.

• Clients under the age of 16 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 18.

• Except in cases of emergency, I agree to pay for 50% of my appointment's fee if cancelled within 24hrs.

• Except in case of emergency, I agree to pay 100% of my appointment's fee if I do not show up for my appointment.

• Cancellation and no show policies apply to the Gift Certificates.

• By signing this release, I hereby waive and release my practitioner from any and all liability, past, present, and future relating to Thai massage therapy and bodywork.