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
Have you had a lymphatic drainage or wood therapy in the last 2 months?
If 'Yes', please state the reason and treatment being received
Do you have any allergies?
If 'Yes', please describe
Are you currently taking any medication? (please include any type of contraception)
If 'Yes', please list the medications and reasons for taking them
In the last 12 months, did you have any kind of surgery?
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
Are you pregnant or have you given birth in the last two months?
Please review the list and check those conditions that affected your health in the past or are present at the time of treatment. Select the condition. If none applies, please select '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.
I understand that, if my therapist deems it necessary, I will provide written permission from a doctor stating that I can continue with treatments.
If any of the above conditions change in the time between submitting this form and treatment, or in the time between multiple treatments, I will inform the therapist.
I understand that treatments are performed in between two menstrual cycles, and minimum two days after the period ends. (applicable for anti-cellulite treatments only)
I understand that my maderotherapy therapist doesn't promise specific treatment results as they highly depend on a client's condition and aftercare.
The following questions are related to our public liability insurance requirements.
If I experience any pain or discomfort during the session, I will immediately inform my therapist so that pressure can be adjusted to my level of comfort. It is important to report discomfort to your therapist to avoid unnecessary bruising. I will not hold my therapist responsible for any pain or discomfort experienced during or after the session
I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness.
I affirm that I have notified my therapist of all of my known medical conditions and injuries. I agree to inform the therapist of any changes in my health and medical condition.
I understand that, if my therapist deems it necessary, I will provide written permission from a doctor stating that I can continue with treatments.
Do you agree to have your photos posted on Facebook and/or Instagram in favour of and to improve provision of my business? (All photos will be anonymous and faces will be hidden)
If I am up to 15 minutes late, treatment will only last until the end of the scheduled appointment.
I understand that, in the event of being more that 15 minutes late, treatment will be cancelled.
I understand that the notice of 24 hours is required, if I can't make it to my appointment.
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.
Date

MonthDayYear
Date
Signature
Name

First NameLast Name
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