Maternity Reflexology Client Consultation Form Please complete and submit the consultation form below: Fields marked with an asterisk * are required fields Client Name *Date *Profession *Telephone No. (Mobile) Telephone No. (Landline) Email Address Client Address Reason for seeking therapy *GP name, address and telephone no. *1st Day of Last Period (Day 1) Or weeks pregnant Due Date * I (please fill out name below) confirm that: I am not pregnant having taken a reliable pregnancy test today or have other reasons to know and be sure I am not currently pregnant. ORDuring my current pregnancy I do not have any of the conditions listed below and that I understand are a risk to my pregnancy. I therefore give Heather Morris permission to give maternity reflexology to me. 1. Placenta praevia - placenta is lying unusually low in the uterus, next to or covering the cervix 2. Placental abruption - placental lining has separated from the uterus of the mother prior to delivery. It is the most common pathological cause of late pregnancy bleeding. 3. Bleeding 4. Continuous Vomiting 5. HELLP Syndrome - life-threatening liver disorder 6. Toxaemia: Pre-Ecclampsia – Ecclampsia - high blood pressure and often a large amount of protein in the urine. Usually occurs in the third trimester 7. Pica Syndrome and DVT – Deep Vein Thrombosis. Conditions that require sign off from your midwife or specialist. Diabetic mother Cardiac disorders – heart disease Chronic Hypertension Previous pregnancy problems – miscarriage Mother under 20 or over 35 Asthmatic mother Exposure to drugs Previous multiple births Suspected RH negative mother or other genetic problems Midwife Name Midwife No. Clients signature required during appointment if completing on line VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: