Name:
First Name
Last Name
Date:
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Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Occupation:
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Referred By:
Emergency Contact: Name / Relationship / Phone
For what reason are you seeking Manual Lymphatic Drainage?
Medical Reason
Relaxation
If you are here for medical issue, when did the problem start?
Please describe your problem including where it is and its severity.
Please list all surgeries (including Cesarean section). Surgery/Date/Hospital and Surgeon
Please list ALL medications (including vitamins, hormones, and herbs) and reason for prescription. Medication/Reason
Is there anything else that your MILD therapist should know about you or your needs before this session?
Are you currently undergoing cancer treatments? Yes or No
If yes, do you have written permission from your treatment team to receive Manual Lymphatic Drainage, at this time?
If no, what was the date of your last treatment?
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Month
-
Day
Year
Date
For Prenatal Clients: Are you still experiencing morning sickness?
Have you been told you are a high risk pregnancy?
For Medical Referral Clients: Do you give your therapist permission to consult with your referring provider for your protected health information for the purpose of this visit?
Yes
No
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 practitioners part should I fail to do so.
Date
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Month
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Day
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Date
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