Leave this field blank Contact Info First Name Last Name Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zipcode Mobile Phone Email How Did You Find Us? Search Facebook Instagram Find a Foot Zoner Near Me Site Referred By Friend Who Referred You? Zoning Info Date of Birth Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Medical Conditions, Diagnosed Conditions, Concerns, Aches & Pains, or Allergies: Please list any surgeries or implants including pacemaker, screws, metal plates, or IUD's etc. Please note: I am not a doctor I do not practice medicine I do not diagnose or treat specific illnesses I do not prescribe or adjust medication Foot Zone therapy is not a substitution for medical treatment, but is a compliment to most other types of therapy By signing this form, you give your consent to a foot zone session. You understand that you may discontinue this session or future sessions at any time. If you have been diagnosed by a licensed health professional as having any disease, injury, or other physical or mental conditions, you understand that you should inform the person who made the diagnosis about the sessions you will be receiving. If you intend to discontinue any treatment or therapy which had been previously ordered, prescribed or recommended by a licensed health professional, you understand you assume responsibility for any negative outcome resulting from discontinuing that treatment or therapy. A Foot Zone Practitioner may not diagnose disease, injury or disfigurement. Only licensed health professionals may perform diagnosis. Foot Zone Therapy is not a substitute for medical care. If you are experiencing any specific medical problem, please seek medical care. Signature Start drawing Clear Done Start over Print Name Signature Date Send Save draft
