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 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
