Health Intake Form | Serenite WellnessCA

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First name*

Last name*

Email*

Phone*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Occupation

Medical Conditions *

Surgical History*

Medications and Reasons for taking them*

By checking this box, I am confirming I do not have any contagious skin conditions, including Fungus or Athlete's Foot

Have you had Reflexology before?

Yes

No

Do you have sensitivities to Essential Oils?*

Yes

No

Do you have sensitivities to Lotion*

Yes

No

There is pulling of the Leg, do you have any joint or tissue issues from the hip down? *

Yes

No

How did you hear about Serenite Wellness?*

By checking this box, I am confirming I have answered the above to the best of my knowledge.

Signature*

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ACCESSIBILITY STATEMENT

Text & Call

519-257-9292

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Email

jess@serenitewellness.com

Medical Disclaimer: Jessica Serre and Serenite Wellness do not replace medical care or treatments. If you have a medical emergency, please call 911 or go to the nearest emergency room. If you are under the care of a Primary Care Provider or Specialist, please consult them prior to initiating Complimentary Alternative Medicine treatments.

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