Lymphatic Drainage Form
Divine Spa and Body
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
What date was your surgery?
*
-
Month
-
Day
Year
Date
Which surgical procedure did you have?
*
How many days post-op are you?
*
Have you had any other previous cosmetic procedures?
*
Are you under medical supervision? (besides your surgeon)
*
Yes
No
Did your surgeon approved this service as part of your recovery?
Yes
NO
Has your doctor limited you from laying on your back or front?
*
Yes
No
Are you dealing with CELLULITIS, RASH, MAJOR SCARS, LUMPS OR OTHER?
*
Yes
No
Do you have any allergies to lotions or scents? If yes, what are they?
*
Hospital and Surgeon name?
*
How did you hear about us?
Today's Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: