New Lymphatic Massage Consent

Name

First NameLast Name

Any recent surgeries?

Have you undergone any treatment for cancer?

Have you ever had lymph nodes removed or radiated?

Do you have any conditions that affect your cardiovascular function? Cardiac arrhythmias? Palpitations?

Do you have any conditions that affect your kidney function?

Do you have any concerns with your thyroid function?

Do you suffer from varicose veins?

Do you ever experience dizziness or fainting spells?

Do you suffer from high or low blood pressure?

Do you suffer from chronic inflammation?

Do you experience any allergies?

Do you have any digestive system concerns such as IBS, Crohn’s Disease, or intestinal inflammation?

Do you have any implanted devices?

Are you currently pregnant?

Do you experience difficulty sleeping?

Current Medications:

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. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork 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 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 very powerful modality and certain medical conditions are contraindicated and determine if and when you can receive a session. 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. Please understand this is for your safety and well-being.

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