Client Information

First Name*
Last Name*
Phone*
Date of Birth*

MonthDayYear
Address*
City*
State*
ZIP*
E-mail*
Gender

FemaleMaleWould rather not say
Referred by:*

FlyerAnother clientSmall street signsChiropractorPhysical TherapistLocal EventFacebookRadioNewspaperInternetYellow Pages
If another client or chiropractor referred you, please put their name
Your Occupation
In case of Emergency (Name and Contact Number)*
Have you ever experienced a Manual Lymphatic Drainage session?*

YesNo
If yes, how recently?
What are your goals for this session?*
HEALTH HISTORY Please check the box next to the items that apply to you:*

High StressDiabetesFrequent HeadachesPregnantArthritisWear Contact LensesWear DenturesHigh Blood PressureLow Blood PressureEpilepsy / seizuresJoint SwellingVaricose VeinsContagious DiseasesOsteoporosisAllergiesBruise EasilyBroken Bones in the past 2 yearsInjuries in the past two yearsCardiac or Circulatory problemsBack painNumbnessStabbing painSensitive to touch or pressure in any areaPacemakerMetal in your body from any type of surgeryNone of these apply to me
For clients undergoing cancer treatments:
What was your diagnosis?

Please answer the following:

	Yes	No
Are you currently undergoing cancer treatment?
Are you currently undergoing radiation treatment?
Did your doctor recommend MLD?
Do you have written permission from your treatment team to receive MLD at this time?
Are surgical sites healed?

What was the date of your last treatment?
Do you give written permission to contact your treatment team to receive MLD at this time?
Were drains used in the procedure? If so, how many?
Date of last chemotherapy session?
How many sessions have you had? How many are recommend?
How many radiation sessions have you had? How many are recommend?
Please describe the full procedure and if there were any complications.
For clients who have received cosmetic surgery procedures:

Please answer the following:

	Yes	No
Did your surgeon recommend MLD?
Have you been cleared by your doctor to receive MLD?
Have you already received MLD after surgery?

If you've already received MLD post surgery, how many sessions did you have? Where did you receive them?
Are in you pain? If so, where?
Are you experiencing swelling or bruising? If so, where?

Please answer the following:

	Yes	No
Did you have issues with blood clots or clotting?
Were drains used following the procedure?
Were you in a compression garment?
Are you wearing post-surgical garments?
Are you noticing thickening or fibrosis?

Please mark ALL surgeries/procedures:
Liposuction:

360AbdomenWaist/FlanksArmsHips/buttocksBackThighsInner KneeCalves & AnklesNeck/Chin
Breast:

Augmentation - ImplantAugmentation - Fat transferLiftRemovalImplant RevisionRevisionNippleRemovalReconstructionExpandersAreola RemovalAreola Reconstruction
Body Lifts:

Arm LiftBody LiftMommy MakeoverBody ContouringAbdominoplastyBBLHip Augmentation
Neck & Face:

Face liftRhinoplastyEyes/BrowCheek AugmentationNeck/Chin
Gender Confirmation Surgery:

Transfeminine - FacialTransmasculine - FacialTransfeminine - ChestTransmasculine - Chest
Please provide all the details of your recent surgery (date, hospital/clinic, surgeon):
Please list ALL medications and reason for taking them. Please note if it is related to the surgery:
Please describe and provide dates:
Prior Surgeries:
Auto Accidents:
Falls/Injuries:
Pregnancies:
Is there anything else that your therapist should know before your session?
Please indicate areas that need focus.*
Please indicate areas to be avoided.*
Please indicate areas that are ticklish.*
I understand that the Manual Lymphatic Drainage I receive is provided for the basic purpose of improving the flow of my lymphatic system and also for relaxation. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage or bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialists for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnoses, 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 massage/bodywork 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 practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner's part should I fail to do so. I understand that the practitioner may end the massage session if the practitioner feels uncomfortable for any reason. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.
Consent to Treatment of Minor

By submitting this form, I hereby authorize the practitioner to administer massage, bodywork, or somatic therapy techniques to my child or dependent as they deem necessary.
Name of Parent/Guardian (if consenting for a minor)
Please click the submit button below after reviewing the following information.

The therapist will review your health and medical information. They will discuss the type of massage therapy services or techniques the therapist anticipates using during your session. They will described the body parts that will be massaged. Standard draping will be used during the session unless otherwise agreed to by both the client and the therapist. You can stop the massage at any point in time for any reason. Breast massage is not performed without written consent.
Beni Massage and Wellness reserves the right to refuse, postpone or terminate treatment whenever we deem it in the best interest of one or more of the parties. Please initial below*
Release of Records/Permission to Communicate Consent: I hereby give Beni Massage and Wellness consent to communicate with any and all practitioners involved in my treatment as they deem necessary. Initial for consent
Photo Release (optional): I consent to taking of before and after photographs for the purposes of assessing treatment effects and for promotional use by the facility. I understand my identity will be protected unless I provide specific permission otherwise.*

I consentI do not consent
Late/Cancellation Policy

Please arrive at least 5 minutes* before your scheduled appointment time in order to ensure a full massage session. * If you are a new client, then you will need to arrive 5-10 minutes early to go over paperwork. Clients arriving late will receive the rest of their appointment time and will be charged for the full scheduled appointment time. Clients arriving more than 15 minutes late will be rescheduled. You may cancel your appointment without charge 24 hours before your appointment. Cancellations less than 24 hours before session will be charged 25% of the scheduled service; less than 12 hours will be charged 50%. • If you do not call to cancel your appointment or do not show up for your scheduled appointment, you will be charged 100% for the scheduled service.
Sick Policy

Both therapists and clients are vulnerable to infection from contagious illnesses. If you come in sick, it can worsen your condition. Please reschedule your appointment if you are feeling unwell. Clients with any of the following illness, or any other contagious illness not listed, will be rescheduled: Vomiting, fever, cold, influenza, diarrhea, measles, mumps, rubella, chicken pox, head lice, scabies, impetigo, meningitis, conjunctivitis, hepatitis A, thrush, polio, ringworm of the body, feet or scalp, meningococcal disease, and whooping cough.
Confirm below that you acknowledge the policies above*

I acknowledge and have full understanding of the policies.
I understand that all treatments at this facility are therapeutic is nature. I agree to communicate to the therapist any physical discomfort or draping issues during the session. *

I agree
I understand the building that Beni Massage and Wellness is located in a building that locks automatically in the evenings and on the weekends. I will wait for the therapist to open the door for me and will not leave before my appointment time. I recognize if I leave before my appointment time that I will be charged a no show fee. Beni Massage and Wellness is located in a 2 story red brick building with green awning in front of the Megaton Brewery.*

I agree
An individual who wishes to file a complaint against a massage therapist, a massage therapy school, a massage therapy instructor, or a massage therapy establishment may write to:

Complaints Management and Investigation Section P.O. Box 141369 Austin, Texas 78714-1369.Call 1-800-942-5540 to request the appropriate form or obtain more information
Massage Therapist Signature

Clear
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

For clients undergoing cancer treatments:

For clients who have received cosmetic surgery procedures:

Please mark ALL surgeries/procedures:

Please describe and provide dates:

Consent to Treatment of Minor

Please click the submit button below after reviewing the following information.

Late/Cancellation Policy

Sick Policy

An individual who wishes to file a complaint against a massage therapist, a massage therapy school, a massage therapy instructor, or a massage therapy establishment may write to: