• Lymphatic Drainage Form for Wellness Or Post-Op Care

  • CLIENT INFORMATION

  • Format: (000) 000-0000.
  • Gender*
  • Birthday*
     - -
  • Format: (000) 000-0000.
    • How would you like to provide your gift card details? 
    • Are you using a Gift Card / Gift Certificate?
    • Are you using a Spafinder/Spaweek or Somatic Massage spa gift card?
    • How would you like to provide your gift card details?
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    • LYMPHATIC DRAINAGE SESSION INFORMATION

    • What is the purpose of your Manual Lymphatic Drainage session?*
    • Have you received Lymphatic Drainage or Post-Op Care before?
    • Have you ever had a thermography scan?
    • What are your primary goals for lymphatic drainage today? (Check all that apply)*

    • ⚠️ IMPORTANT: You selected options NOT appropriate for lymphatic drainage. Lymphatic drainage uses very light touch and cannot address muscle tension or pain. Please book Deep Tissue, Swedish or Clinical Massage instead. Call 516-686-9557 or see front desk to change your booking.

    • Are you currently experiencing pain?
    • Are you currently experiencing swelling?
    • Click the arrow If you did not have surgery 
    • Do you notice any thickened or fibrotic areas? (Post Surgery)
    • Please list/date all previous surgical procedures:
    • Did you stay at a recovery house?
    • Did your surgeon or post-op team recommend massages or Lymphatic Drainage?
    • Were drains used following your procedure?
    • If yes, are drains currently in?
    • Are all incisions healed?
    • Has any fluid needed to be removed with needles/syringes?
    • Are you currently seeing a healthcare professional?
    • What stage compression garment are you currently in?
    • Are you wearing foam pads under your compression garment?
    • We offer complimentary lymphatic drainage herbal tea to enhance your treatment results. Would you be interested in trying this?

    • CONSENT FORM

    • 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.

       

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