In Case of Emergency Contact

Name of Primary Care Physician:

Please answer the questions below. They will be used to help plan your therapy.

Are you allergic or sensitive to any creams/oils (essential oils, nut oils, scents)?

Yes No

Are you pregnant?

Yes No

How far along are you?

Are you currently under medical supervision?

Yes No

Are you currently taking any medication?

Yes No

Do you have high or low blood pressure?

Yes No

Do you wear

Contacts Dentures Hearing aid Other

Are you seeking therapy for medical issues?

Please check any condition listed below that applies to you:

Please describe your main complaint including where it is and its severity.

Any information (medical or other) about the conditions you marked or not specified above that you feel is important for the practitioner to know:

Please take a moment to read the following statements:

I affirm that I have notified my therapist of all known medical conditions and injuries and that I will notify my therapist of any changes in my health and medical condition.

I understand that massage is entirely therapeutic and non-sexual in nature.

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort.

I understand that the services offered today are not a substitute for medical care. I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.

Lymphatic Drainage

I understand that the Manual Lymphatic Drainage I receive is provided for the basic purpose of improving the flow of my lymphatic system and also for relaxation.

Because Lymphatic Drainage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the practitioner updated as to any changes in my medical profile and I understand that there shall be no liability on the practitioner’s part should I fail to do so

Please Note: Manual Lymphatic Drainage (MLD) is a powerful modality and certain medical conditions are contraindicated. After the consultation and review of the information you have provided on this form, it will be determined if MLD should be administered to you today. Some conditions will require a note from your doctor before proceeding.

I understand that should I cancel an appointment less than 24 hours before the schedule time or “no show” an appointment, I am subject to a fee equal to the cost of the missed appointment.

I have read and agree to the policies therein.

Manual Lymphatic Drainage Intake Form

Explore

Address