CLIENT INTAKE FORM - Maderotherapy treatment

CLIENT INTAKE FORM - Maderotherapy treatment

Before your appointment, I ask you to please answer the questions on this form. All information will be kept confidential. This information will never be disclosed or shared without the client's written consent. The form must be submitted 24 hours before the first treatment to ensure enough time for the therapist to get familiar with your medical history and condition, as well as to ensure you get the best treatment possible.
Name

First NameLast Name
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
YesNo
If 'Yes', please state the reason and treatment being received
YesNo
If 'Yes', please describe
YesNo
If 'Yes', please list the medications and reasons for taking them
YesNo
Please note that Maderotherapy is not performed as post-operative treatments, I can only accept clients with completely healed wounds and reduced swelling.
If 'Yes', please describe
YesNo
Contagious disease (bacteria, fungi, viruses)*Autoimmune disease*BruisingComplicated recent dental workCancer*Broken/Dislocated bones*Blood clots*Blood pressure (high/low)Cardio vascular disease*DiabetesGynecological infections*Depression or other psychological conditionHepatitis (A, B, C or other)*Jaw issues (pain, tightness, dislocation, locked jaw,...)Hernia*Lymphatic system disease (lymphoma, lymphangitis, lymphangioma,lymphadenopathy,...)*Intestine diseases or blockages*Inflammatory conditions (thrombosis, phlebitis, lymphedema, lipedema,lipohypertrophy,...)*Liver disease*Kidney disease*Epilepsy*Neuritis*PregnancyRenal failure*Radiation cystitis, radiation colitis*Skin burns*Skin rash*Thyroid diseaseUndiagnosed lumps and bumps*Undiagnosed painSpider veinsVaricose veins*None of the above
Please note conditions marked with a star sign (*) are absolute contraindications. In case of an absolute contraindication, our treatments cannot be performed.

Conditions not marked with a star sign (*) are relative contraindications. If deemed necessary, the therapist will contact the client for consultation regarding the selected condition.
Yes, I understand
Yes, I understand
Yes, I understand
Yes, I understand
The following questions are related to our public liability insurance requirements.
Yes, I understand
Yes, I understand
Yes, I understand
Yes, I understand
I agreeI disagree
Yes, I understand
Yes, I understand
Yes, I understand
INFORMATION AND SUGESTION

Prior to your maderotherapy treatment, please remove contact lenses and all jewellery. Pull long hair back with a clip or a band.

In general, clients need to undress for the maderotherapy treatment. However, you may shoes to wear disposable pants to be provided by your therapist.

Please arrive at least five minutes before your appointment.
Please note this form is not a booking. To book a treatment, please send an email to: lela.ljerka@gmail.com or call/text on 0894148488 (Whatsapp)
Being that massage should not be done under certain medical conditions, I affirm that I have answered all questions pertaining to medical conditions truthfully.
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