Post Op Form [Complete]

VV Spa - Post Operation Massage Intake Form
Name
Date of Birth

MonthDayYear
Date
Address
Phone Number
Email
example@example.com
Emergency Contact Name
Emergency Contact Number
Treatments (Please check all that apply)

Post OperativeLymphatic DrainageCavitationPost-TummyLymphatic Massage
Please check all that apply

Do you have any cancer or tumor?Do you have blood clotting?Do you have any contagious disease(s)?Do you have any cardiac problem(s)?Do you have any wounds not healed?Have you ever had internal bleeding?Do you have high or low blood pressure?Do you have any heart problems?Do you have any plastic or metal implants?Are you epileptic?Do you have diabetes?Do you have tuberculosis?Do you have any internal device(s)?Do you have uterine cysts?Do you have any virus?Do you have any wounds on your skin?Do you have a transplant?Have you had any abdomen surgeries?Do you have any infections?Do you suffer from depression or anxiety?
If so with plastic or metal implants, where?
Are you receiving any medications? If yes, which ones?
Please list your medical information down below:
Name of the Clinic / Hospital
Name of your Doctor
Location
I agree and accept to continue these therapies under my full responsibility and I confirm I am over the age of 18.
Signature

Clear
Date

MonthDayYear
Date
POST-OP CARE CLIENT RELEASE AND COMMITMENT FORM / AGREE TO THE FOLLOWING TERMS FOR MY POST-OP CARE SERVICES
1. I agree to keep all my appointments scheduled.

2. I understand and acknowledge all missed appointments are not made up and non-refundable. I understand that I must cancel my appointment 12 hours prior or I will be charged for the full price of that appointment.

3. I will report any significant health issues that may occur during Post-Op care services to include any drainage of fluids form and if necessary will go to the ER. 4. I am aware that all files, photographs and measurements are the property of V.VSpa.

5. I UNDERSTAND THAT V.V SPA IS NOT RESPONSIBLE FOR THE OUTCOME/RESULTS OF MY SURGERY. I MUST CONTACT MY DOCTOR FOR QUESTIONS REGARDING MY RESULTS.

a. Example: lumps, excess fat, and etc.

6. Everything that happens in the appointment will not be shared. 7. I give permission to V.V Spa to use my information for statistical data and photographs derived from my Post-Op care service.

IF I DO NOT AGREE, I CANNOT CONTINUE MY TREATMENT.
Printed Name
Date

MonthDayYear
Date
Signature

Clear
CARE NOTE POST-OP SERVICE
Client name
(Before Session) Any Surgery?

YesNo
Doctor's Name
Name of Clinic / Hospital
Location of Surgery
# Of Weeks (Post Op):
Pain?
Have they gotten any massages?

YesNo
How many?
What area(s) did they focus on?
Where?
Action Taken
ANY OTHER NOTES
Should be Empty:

VV Spa - Post Operation Massage Intake Form

POST-OP CARE CLIENT RELEASE AND COMMITMENT FORM / AGREE TO THE FOLLOWING TERMS FOR MY POST-OP CARE SERVICES

CARE NOTE POST-OP SERVICE