Home - Revive Lymphatic Drainage

Name*

First NameLast Name

Email*

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Phone Number*

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In case of emergency contact*

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Please check all that apply to you*

Surgeon/Clinic

Only if applicable

Date of procedure

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Details of procedure

Please include all areas and procedures completed, only if applicable.

At Revive Body Therapy, our treatments are designed to support lymphatic health, post-surgical recovery, detoxification, and overall wellbeing through specialized Manual Lymphatic Drainage and therapeutic bodywork techniques.

By receiving services, I acknowledge and agree to the following:

I understand that Manual Lymphatic Drainage (MLD) and bodywork services are wellness therapies intended to promote circulation, recovery, and relaxation. These services are not a substitute for medical care, diagnosis, or treatment. Revive practitioners do not diagnose conditions, prescribe treatment, or perform medical or chiropractic procedures.

I confirm that I have disclosed all relevant medical history accurately and will notify my practitioner of any changes to my health, medications, or surgical status. Post-surgical clients acknowledge they have received appropriate medical clearance prior to treatment. Sessions are customized and may be adjusted, postponed, or declined if treatment is deemed inappropriate for safety reasons.

I understand that comfort and communication are essential during treatment and agree to immediately inform my practitioner of any pain or discomfort so adjustments may be made.

Health & Safety Acknowledgment
Revive Body Therapy maintains enhanced sanitation and wellness protocols to provide a safe treatment environment. I understand that close-contact services may carry inherent exposure risks related to communicable illnesses, including COVID-19 or influenza, and I voluntarily accept this risk when proceeding with treatment.

Appointments may be rescheduled if symptoms of illness are present to protect both clients and practitioners

Appointments & Cancellation Policy
Appointments are reserved exclusively for each client. I acknowledge Revive Body Therapy’s 48-hour cancellation policy and understand that cancellations, reschedules, or missed appointments within this window may result in an applicable $50 late cancellation fee or forfeiture of deposits or package sessions.

Media & Testimonial Release

I grant Revive Body Therapy permission to capture photographs, video, or testimonials for educational and marketing purposes, with or without identification. I waive any right to compensation related to such use.

Clients who prefer to be excluded from photography or media content may notify their practitioner at any time prior to treatment.

I prefer to not be photographed or videoed

Preferred time of day for treatments

Preferred days for treatments

How did you hear about Revive?

Consent to Care
I confirm that all questions regarding treatment have been answered to my satisfaction and that I voluntarily consent to receive services at Revive Body Therapy. This agreement applies to my current and future sessions unless revoked in writing.

Signature

Client Consent & Treatment Agreement