Colon Therapy Registration and Screening Health History Form

Manual Lymphatic Drainage Registration and Screening Health History Form

Complete this form for Expedited Manual Lymphatic Drainage ONLY. This information will be used for screening and registration purposes. In order to qualify, you must NOT have any major health issues. Once your form is submitted, we will review your request and if approved, you will be scheduled for a Medical intake by one of our providers and your first Lymphatic Massage. The charge for this visit and session is $376. Manual Lymphatic Drainage Therapy is not advised as a single session, the benefits typically only observed after undergoing six to nine sessions. You are not required to finish this form in one sitting. You have the option to save your progress by scrolling to the bottom and clicking "Save." Then, you will be prompted to create an account which will send you an email with a link to complete this form at your convenience. (If for some reason you do not receive the email with the link, please look in your spam folder.) This form must be completed BEFORE your initial office visit can be scheduled.
Patient's Name*
Date

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Sex*
Date of Birth*

MonthDayYear
Address*
Without special agreement and arrangements, we are unable to accommodate patients who are not ambulatory due to the extra staff necessary for assistance. If you are in a wheelchair and wish to be a patient, you will need someone to come to all sessions with you as an assistant. Are you able to walk without assistance?*

YesNo
Please confirm that you are requesting the Expedited Manual Lymphatic Drainage New Patient visit:

Expedited Manual Lymphatic Drainage New Patient Visit with initial Lymphatic Massage - Only available in the Raleigh office ($376)
A non-refundable application fee and deposit of $100 is payable upon receipt of this form. The balance is owed prior to your initial visit. Once scheduled, patients will be allowed one opportunity to cancel and reschedule at no charge. If this rescheduled appointment is then cancelled again or the patient is a no-show, the patient will need to submit another $100 application fee. No credit will be given for any previous payments made.
If you purchase a package of 3, 6 or 9 lymphatic massages at the time you schedule your Expedited Manual Lymphatic Drainage New Patient , the charge for each session will be $124, A 20% DISCOUNT OVER THE STANDARD RATE. I WOULD LIKE TO ADD THE FOLLOWING LYMPHATIC MASSAGE PACKAGE:

3 Lymphatic Massages - $3276 Lymphatic Massages - $7449 Lymphatic Massages - $1116I will pay for each colonic individually at $155 per session after my New Patient visit.I am interested in a package 6 Lymphatic Massages to purchase at a future time- $883 (5% discount)I am interested in a package of 12 Lymphatic Massages to purchase at a future time - $1296 (10% discount)
Please provide a copy or photo of your driver's license (front and back) or other official identification as required by the US Patriot act. Failure to provide these files will delay scheduling.

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How did you learn about us?
What condition do you hope to address by undergoing manual lymphatic drainage therapy? *
Are you currently under care for this condition?*

YesNo
Explain the care that you are receiving*
Complete Contraindications to Manual Lymphatic Drainage - if you check any of these conditions, you are not a candidate for therapy at this time

Acute untreated infectionsThrombosis or Blood ClotsCongestive Heart FailureMalignant TumorsUncontrolled High Blood PressurePregnancy - first trimesterKidney failureDiabetes with peripheral neuropathyRecent surgery (<8 weeks)
Do you currently take any medications?*

YesNo
Current Medications*
Do you currently take any vitamins or supplements?*

YesNo
Current Vitamins/Supplements*
Do you have any Allergies/Adverse Reactions or Side Effects to Medications?*

YesNo
List Allergies/Adverse Reactions and Side Effects to Medications*
Indicate areas of concern by drawing on the diagram:

X = pain

# = inflammation

O = swelling

Click the "draw button", third from the left the use the mouse to draw one of the above symptoms to indicate areas of concern. You can click the "x" button on the right to start over.
Draw on Image
Please check all that applyi

Abdominal PainAllergiesArthritisAneurysmAutoimmune DisorderBowel ProblemsBlood ClotsBroken BonesBruise EasilyCancerCardiovascular DiseaseChronic BronchitisChronic ConstipationChronic ear infectionsCongestive Heart FailureClotting DIsorderDeep Vein ThrombosisDepression/AnxietyDiabetesEnlarged Lymph NodesFatigueFeverFibrocystic BreastGastrointestinal IssuesHeart AttackHead Injury/ConcussionHematologic/Lymphatic IssuesHigh Blood PressureHIV InfectionInfectionsKidney DisordersLiver DiseaseLow Blood PressureLung DiseaseMigraine HeadachesMajor Organ FailureMajor ScarsMusculoskeletal ProblemsNauseaNeurologic IssuesNeuropathyPainPneumoniaPregnancySinus ProblemsSkin ProblemsStrokeHistory of SurgerySwellingTinnitusThyroid DisordersTransient Ischemic Attack (TIA)Weight GainOther
Hospitalizations, Surgeries and Serious Illnesses*
Health History
Please Provide Details for Any Answers you Checked Above*
Heart/Circulation You MUST check at least one option before you submit this form.*

Rheumatic Fever, Rheumatic Heart DiseaseHigh Blood PressureAngina, Heart PainsHeart DiseaseChest PainPain radiating into your arms, neck, jaw or shouldersAble to lie flat on your back in bedVaricose VeinsPalpitations/Fluttering of HeartSwelling of Head, Feet or AnklesLeg Cramps while WalkingLeg Cramps at NightShortness of Breath after WalkingHeart AttackHeart MurmurStrokeAneurysmAbnormal EKGHigh CholesterolPeripheral Vascular Disease (Poor Circulation)None of theseOther
Neurological/Nerves You MUST check at least one option before you submit this form.*

Seizure disorder/EpilepsyRecurrent VertigoBell's PalsyNeuritis/Inflammation of a NervePinched NerveFrequent HeadachesSevere HeadachesDizzinessUnconscious SpellsInsomnia/Difficulty SleepingNervouse "Tics"FaintingConcussionNone of theseOther
Kidney/Bladder You MUST check at least one option before you submit this form.*

GlomerulonephritisUrethritisKidney StonesFrequent Bladder InfectionsKidney infection/pyelonephritisPainful UrinationDifficulty Starting UrinationFrequency/Urgency of UrinationIncontinence (Involuntary loss of urine)Blood in UrineNone of theseOther
Prior Surgeries - Please Provide Approximate Dates*
Do you have any special diet or food needs?*

YesNo
What percentage of your diet is raw & uncooked?*

0-25%26-50%51-75%76-100%
What is your daily intake of fiber?*
Have you changed your diet since the development of your condition?*

YesNo
Describe changes*
Do you feel this change has improved your health?*

YesNo
No Perfume-Scented Toiletries Policy

For everyone's sake, please be aware of our No Perfume-Scented Toiletries policy and refrain from wearing any perfume or scented toiletries while at the clinic. Non-compliance may result in you being asked to leave and being assessed a cancellation fee.I have read all the information on the Carolina Center website under “New Patients” and “How to Become a Patient” and understand these procedures.I have read the “Orientation Handbook” and understand this information. I am requesting to become a patient of the Carolina Center and understand that it is highly recommended that I attend the “Introduction to the Carolina Center” Group Orientation prior to my visit although this is not required. Please sign and date that you acknowledge this policy.
I certify that the above information is true and correct to the best of my knowledge.

It is my responsibility to inform my physician if there are any changes in any of the information contained in this form.
Patient/Guarantor Signature*

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Date*

MonthDayYear
Insurance Information
Please note that while Carolina Center does not accept Blue Cross/Shield, Medicare or Medicaid and can only file certain claims with other insurance carriers, we are able to utilize most major insurance for certain labs and prescriptions. PLEASE PROVIDE A COPY OF YOUR INSURANCE CARD SO WE CAN HELP YOU FILE CLAIMS IF ABLE. Do you have health insurance?*

Yes, I have a primary insuranceYes, I have primary and secondary insurancesNo, I do not have health insurance
Are you the policyholder on this primary insurance?*

YesNo
Front of primary insurance card. *

Cancelof
Back of primary insurance card. *

Cancelof
Subscriber's name*
Birthdate of subscriber*

MonthDayYear
Sex of subscriber*
Relationship to patient*
Are you the policyholder on this secondary insurance?*

YesNo
Front of secondary insurance card. *

Cancelof
Back of secondary insurance card. *

Cancelof
Subscriber's name*
Birthdate of subscriber*

MonthDayYear
Sex of subscriber*
Relationship to patient*
Emergency Contact Information
Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
HIPPA Privacy Authorization Form

Do you wish to authorize Carolina Center for Integrative Medicine to release any and all medical information and test results that pertain to you, to someone else?
Signature

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I certify that the above information is true and correct to the best of my knowledge. By signing below I agree to all terms and conditions included in this registration and medical history form.

It is my responsibility to inform my physician if there are any changes in any of the information contained in this form.
Signature

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Authorized Person

First NameLast Name
I understand that the Manual Lymphatic Drainage (MLD) I receive is provided for the basic purpose of lymphatic drainage and movement. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the treatment, pressure and/or strokes may be adjusted to my level of comfort. I further understand that MLD should not be construed as a substitute for medical examination, diagnosis, or treatment and that I see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that MLD certified practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because MLD should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances madefy me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

CANCELLATION POLICY: For appointments canceled within 12 hours of session time, the full session fee will be charged. Any clients with a no show or late cancellation (within 12 hours) of an appointment will be required to put a credit card on file before making another appointment. I attest to have read this policy and agree to the cancellation terms.
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Manual Lymphatic Drainage Registration and Screening Health History Form

Health History

No Perfume-Scented Toiletries Policy

Insurance Information

Emergency Contact Information

HIPPA Privacy Authorization Form