Post-Op Manual Lymphatic Drainage Intake Form

MANUAL LYMPHATIC DRAINAGE CONSENT

Skin & Massage Spa By Bella
Precautions (Please initial each) I agree that I am over the age of 18, am NOT under the influence of alcohol or drugs am NOT pregnant or nursing, and desire to receive manual lymphatic drainage therapy The general nature of manual lymphatic drainage therapy has been explained to me.*
Initials:
I understand that manual lymphatic drainage treatments are not suitable for everyone and the risks include but are not limited to allergies to massage lotions, oils /or creams, breaks in the skin, bruising, soreness, tissue damage swelling, redness, and pain during or after treatment. Manual lymphatic drainage therapy may aggravate some medical conditions.*
Initials:
I understand that the therapist is not a physician and does not diagnose illness or disease or any other medical or mental disorder, I further understand that manual lymphatic drainage massage is not a substitute for medical examination however, the massage therapist must be fully informed of my existing medical conditions *
Initials:
I agree that I completed the medical history form provided by my therapist and disclosed any conditions I have or have had previously. It is my responsibility to keep my medical history up to date and inform my therapist.*
Initials:
I understand and acknowledge that payments for the above services are non-refundable. I further agree to provide Skin & Massage Spa By Bella a 24-hour notice of a cancellation or change in appointment time, or I will forfeit a treatment off my package since treatments are by appointment only.*
Initials:
I agree to hold Skin & Massage Spa By Bella harmless from any injury or damages as a result of misinformation provided by me or unknown underlying conditions not disclosed. By my signature below, I certify that I have read and understand the contents of this consent form.*

Powered by Jotform SignClear

	DIGESTIVE
Irritable Bowel Syndrome
Ulcerative Colitis
Diverticulosis
Celiac
Crohn's disease
Ulcers
Cirrhosis
Hepatitis
Gallstones

	SKIN
Rash/Eczema
Psoriasis
Acne
Herpes
Cold Sores
Fungal Infection
Athletes Foot
Warts
Boils
Impetigo
Lice
Skin Cancer

	NERVOUS SYSTEM
Peripheral Neuropathy
Pinched Nerve
Numbness
Tingling
Parkinson Disease
Tremor
Anxiety Disorder
Depression
Eating disorder
Migraines
Seizure Disorder
Sleep Disorder
Shingles

	MUSCULOSKELETAL
Bone or Joint Disease
Gout
Tendonitis
Jaw Pain (TMJ)
Arthritis
Osteoarthritis
Rheumatoid arthritis
Fibromyalgia
Lupus
Lyme Disease
Osteoporosis
Osteopenia
Spinal Problems

	OTHER
Caffeine Use
Tobacco Use
Stress

Photo and Video Release Form

Skin & Massage Spa By Bella
I hereby authorize Gabriela Garcia with Skin & Massage Spa By Bella LLC, to use images of me and/or my property for any artistic or commercial purpose, including advertising, publication, or illustration, as long as my face is not displayed publicly in the photos.

The images can be used in any media format, whether printed, digital, or online and can be combined with other material or distorted images. Gabriela Garcia with Skin & Massage Spa By Bella LLC, is also permitted to use fictitious names in conjunction with the images.

I release and discharge Gabriela Garcia with Skin & Massage Spa By Bella LLC from any, and all claims that may arise out of the use of the photographs and video featuring me, my image, or my property. This includes claims for violation of the right of publicity, right of privacy, or libel. I waive any rights to review or approve any uses of the photographs and video featuring me, my image, or my property.

I hold Gabriela Garcia with Skin & Massage Spa by Bella LLC, harmless from all liability and causes of action that may arise from the use of the images.

This release agreement is fully understood, and I sign it of my own free will.
Late Policy:

Skin & Massage Spa By Bella
Late Policy: Each session at the Skin & Massage Spa By Bella can last up to an hour and a half. Clients are allowed a 15-minute grace period for arrival at each session. If you know you are going to be late, please notify the spa staff as soon as possible.

If you arrive within 15 minutes of the scheduled start time, the session will still end at the originally scheduled time, which means you'll have less time for your treatment. This is to ensure that the next client is not delayed.

If you arrive more than 20 minutes late, fail to cancel a previously scheduled appointment 24 hours before the start time, or do not show up for your appointment, you will be charged the full amount of the appointment. If you have a package, one appointment will be deducted from the package, and no makeup appointment will be allowed.

We appreciate your understanding and cooperation with this policy, as it helps us provide the best service to all our clients.
Client Full Name*
Print Name:
By signing below, I hereby acknowledge that I have completely read and fully understand the above information and release agreement.*

Powered by Jotform SignClear
Skin & Massage Spa By Bella LLC,

3881 W 3500 S Suite#118

West Valley City, Utah 84128

801-837-8304

https://skinandmassagespabybella.com/
Should be Empty:

Post-Op Manual Lymphatic Drainage Intake Form

MANUAL LYMPHATIC DRAINAGE CONSENT

MEDICAL HISTORY

Photo and Video Release Form

Late Policy: