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For clients with issues with Fertility (includes supplemental questions).
Client Consultation Form for Reflexology (Hand/Foot, Ear, Nerve, Face & Maternity), Acupuncture, Japanese Reiki, & Ayurvedic Treatments.
Supplemental forms available for Fertility/IVF/Maternity/Babies/Children >16yrs
DRU Yoga & Pregnancy Yoga. All information is treated in the strictest confidence. If you are unable, or do not want to fill in this web based consultation form online then it can be emailed separately on request and you can print and bring it on the day, or email it back. A form can also be posted to you, or you can collect the form on the day and fill it in during the treatment time. All options are available ~ just ask! drjones@paradiseclinic.co.uk or call/text 07896 047 660
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Medical History |
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IVF or other fertility treatment supplemental information
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By submitting this form you agree to tell the therapist if there are any changes to any of the information in this or the supplemental forms.
Disclaimer: I accept that the information provided is a true and accurate reflection of my state of health. I give permission for treatment to be carried out. I have had each treatment explained to me and accept full responsibility. I will not change any medication I am taking without first consulting my medical practitioner and if I am taking anti-depressants I have my doctor's approval for treatment. I realise that my Dr Melanie Jones PhD is not a medical doctor, and cannot prescribe, diagnose or treat for a specific condition. . Reflexology for example can relieve tension which in turn helps to improve nerve and blood supply and to bring the body into balance. For Ear Reflexology I agree to remove the tourmaline balls 48 hours after treatment, leave them off for 48 hours and then re-apply more tourmaline balls. This application cycle can be continued until the issue has stabilised.
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