Lymphatic Massage Intake Form

3095 MARSHALL HALL ROAD, BRYANS ROAD, MD 20616

Lymphatic Massage Intake Form
Name:
Are you a new Bodi’Oasis Client? Yes No
Address:
Phone:
Email:
example@example.com
Emergency Contact:
Relationship to client:
Primary Physician/Name and Contact Number
Reason for Lymphatic/Location of procedure:
Personal Health History: Please write down past or current symptoms for each category/circle all that apply
Swelling
Tinnitus
Other:
PLEASE CIRCLE AREA DRAINAGE IS REQUIRED
What is the reason you are seeking lymphatic massage today?
For Cancer Clients:
Are you currently undergoing cancer treatments? If yes, do you have written permission from your treatment team, to receive Manual Lymphatic Drainage,

If no, what was the date of your last treatment?
if no, what was the date of your last treatment?

Month Day Year
Date
For Prenatal Clients:
Are you still experiencing morning sickness? Have you been told you are a high risk pregnancy? from your Obstetrician to receive Manual lymph drainage at this time?

If Yes, Do you have written permission
For Medical Referral Clients:
Do you give your therapist permission to consult with your referring provider your protected health

information for the purpose of this visit? No
Yes
I authorize the release of medical records or other health care information, including intake forms, chart notes, reports, correspondence, billing statements, and other written information to my attorneys, healthcare providers, and insurance case managers, for the purposes of processing my claims.
signature

Clear
(Please inform your practitioner immediately upon signing any exclusive Release of Medical Records with your attorney that may impact the above release statement.)
Medications currently taking:
Please provide any other information, medical or otherwise, not specified in this intake form that you feel
is important for the therapist to know:
*Please note: Manual Lymphatic Drainage (MLD) aka Lymphatic Massage, is a very powerful modality, and certain medical conditions are contraindicated and determine if and when you can receive a session. After 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, or consultation between your referring provider and lymphatic therapist, before proceeding. Please understand this is for your safety and well-being. I understand that manual lymphatic drainage should not be considered a substitute for medical examination, diagnosis, or treatment, and I should see a physician, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that lymphatic therapists are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the sessions should be construed as such.

Manual 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 and to the best of my knowledge. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner or Bodi’Oasis Wellness Spa’s part should I fail to do so.
Client Signature

Clear
Practitioner Signature:

Clear
Date:

Month Day Year
Date
Should be Empty:

3095 MARSHALL HALL ROAD, BRYANS ROAD, MD 20616

PLEASE CIRCLE AREA DRAINAGE IS REQUIRED

For Cancer Clients:

For Prenatal Clients:

For Medical Referral Clients: