Lymphatic Drainage For Wellness And Post-Op Care: Use ONLY For Post Surgeries And Wellness Detox

Have you received Lymphatic Drainage or Post-Op Care before?

YesNo

If yes, please tell us the date of your last Manual Lymphatic Drainage:

What are your goals for this session?

(What is your reason for seeking Manual Lymphatic Drainage, your chief concern?)

Are you currently experiencing pain?

YesNo

If yes, where?

Are you currently experiencing swelling?

YesNo

If yes, where?

Do you notice any thickened or fibrotic areas?

YesNo

If yes, where?

How long have you had these symptoms?

What medical instructions are you following for these symptoms?

What (if any) positions make you feel better?

Laying down, on stomach, etc.

Please list/date all previous surgical procedures:

name of your surgeon(s)

How was your post-surgical care?

Did you stay at a recovery house?

YesNo

If yes, how long?

Did your surgeon or post-op team recommend massages or Lymphatic Drainage?

YesNo

If no, how did you know to seek massage/Lymphatic Drainage?

Were drains used following your procedure?

YesNo

If yes, are drains currently in?

YesNo

Are all incisions healed?

YesNo

Has any fluid needed to be removed with needles/syringes?

YesNo

If yes, how often?

How many massage sessions have you received following your procedure?

Are you currently seeing a healthcare professional?

YesNo

What stage compression garment are you currently in?

Stage 1Stage 2Stage 3

Are you wearing foam pads under your compression garment?

YesNo

Please list any health conditions that have affected you recently or in the past

Including skin, digestive, reproductive, musculoskeletal, respiratory, or nervous system conditions or concerns.

Please specify any allergies or sensitivities:

Including latex, fragrance, AHAs, penicillin, pollen, etc.

Please list any/all medications or herbal supplements you are currently taking

Any other symptoms or concerns?

Show us your pain, discomfort, swelling, or bruising areas:*

SCOPE OF PRACTICE
Massage therapy is a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, with the intention of positively affecting the health and well-being of the client. Massage Therapists do not diagnose or prescribe for medical conditions nor are they allowed to provide treatment for a specific condition without a doctor's supervision. The massage therapist is required to refer you for diagnosis and to follow recommendations of your physician. The massage therapist is happy to adjust pressure, table temperature, work longer on an area, or move on if you request it.

MEDICAL CONDITIONS
It is the responsibility of the client to keep the massage therapist informed of any medical treatment currently being taken, and to provide written permission from the physician, physical therapist, etc., that the massage may be continued. The client must also keep the massage therapist informed of any changes in health conditions.

Appointments and Cancellation Policy

All services require a valid credit card or gift certificate to secure your reservation. Your card will not be charged at the time of booking.

Understanding Our Policy
We understand that unforeseen circumstances can arise. However, when you book an appointment, we reserve that time specifically for you. Last-minute cancellations or no-shows significantly impact our ability to serve other clients and our therapists' schedules.

Cancellation and Rescheduling
If you need to cancel or reschedule, please notify us at least 24 hours in advance by calling or texting:

Phone: 516-686-9557 (voicemail is checked frequently)
Text: 516-447-4373

Fees for Late Cancellations, Same Day Reschedule and No-Shows

Cancellations with less than 24 hours' notice will incur a cancellation fee equal to 100% of the scheduled service cost.
Clients who do not show up for their appointment without any prior notification (no-shows) will be charged 100% of the scheduled service cost.
Gift certificates will be considered fully redeemed for any missed appointments without prior notice.

Agreement to Policy and Charges
By signing this intake form, you acknowledge that you have read, understood, and agree to our Appointments and Cancellation Policy. You authorize Somatic Massage Therapy, PC, dba Somatic Massage Therapy & Spa, to charge the credit card on file for any applicable cancellation or no-show fees as outlined above.

My signature acknowledges that I have read and agree to receive the Lymphatic Drainage and that I will adhere to all of the aforementioned statements that I have checked off. I agree to waive all liability toward my technician and the spa for any injury or damages incurred due to any misrepresentation of my health. I have read and fully understand the above Appointment Cancellation Policy and agree to be bound by it's terms. I agree to pay the cancellation fee in the event of a missed appointment. I understand that this consent agreement is legal and binding. *

Today's Date

Date

Lymphatic Drainage Form for Wellness Or Post-Op Care

CLIENT INFORMATION

MASSAGE INFORMATION

CONSENT FORM