Client Intake & Consent
Welcome to LymphAddict and thank you for choosing our services. We kindly request that you complete this form in its entirety to ensure safe and personalized care. All information collected is strictly confidential and will be used to customize your treatment plan. Please discuss any questions or concerns with staff prior to commencing treatment. Let's get flowing!
Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Permission to contact you via email for promotional purposes?
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Yes
No
How did you hear about us? (e.g., referral, website, Instagram, Google, other)
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Current weight
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Please use pounds (lbs) not kilograms
Height
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Have you experienced any of the following health conditions past or present? (Select all that apply)
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None
Heart disease or cardiovascular issues
High or low blood pressure
Diabetes Type 1
Diabetes Type 2
Thyroid disorders
Autoimmune disorders
Cancer (past or present)
AIDS/HIV
Kidney or liver disease
Lymphedema or lymphatic system disorders
Lipedema
Blood clotting disorders
Skin conditions
Chronic pain or fibromyalgia
Neurological conditions
Respiratory conditions
Circulatory conditions
Irritible Bowel Syndrome
Horomonal imbalances (PCOS, menopause, etc.)
Spider veins
Varicose veins
Please specify any other health conditions or concerns not listed above.
Are you currently taking any medications or supplements?
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Yes
No
Please list any medications, supplements, or treatments you are currently using.
Allergies or Sensitivities (Select all that apply)
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None
Latex
Medications
Topical products
Other
Please list ALL surgeries or medical procedures (in the past 5 years or within the next 24 months), including dates and procedure(s) performed.
Do you have any medical devices or implants?
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Yes
No
Do you have any areas of heightened pain or sensitivity?
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Yes
No
Skin & Tissue Health (Select all that apply)
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None
Open wounds, cuts or burns in treatment area
Active infections
Recent tattoo or piercing in the treatment area
Scarring or keloids
Other
Do you have any current infections or skin conditions?
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Yes
No
Please describe any current infections or skin issues.
Are you currently pregnant or breastfeeding?
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No
Pregnant
Breastfeeding
Trying to conceive
Postpartum (less than 12 months)
How would you describe your daily water intake?
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High (2+ litres)
Moderate (1-2 litres)
Low (under 1 litre)
Dehydrated (under 500ml)
How often do you exercise?
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Daily
3-5 times per week
1-2 times per week
Rarely/Never
Do you follow a specific diet (e.g., keto, vegan, gluten free, etc.)
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Yes
No
Other
Alcohol Consumption
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Non-drinker
Occasional/Social
Frequently
Smoking & Drug Use (Select all that apply)
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Non-smoker
Current smoker
Former smoker
Cannabis
Vape
Other
How would you rate your current stress level?
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High
Moderate
Low
Approximately how many hours of sleep do you get per night?
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Which service(s) are you interested in? (Select all that apply)
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Non-surgical body contouring
Manual Lymphatic Drainage
Brazilian Lymphatic Drainage
Pre or Post Surgical Care
What are your primary goals for treatment? (Select all that apply)
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Fat reduction
Skin tightening
Cellulite reduction
Colombian Butt Lifting
Double Chin/Jawline sculpting
Sculpting & definition
Detoxification
Swelling & inflammation management
Pain relief
Improved circulation
Post-surgical recovery
Other
Have you received any form of non-surgical body contouring, lymphatic drainage or post-surgical care in the past?
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Yes
No
What are your area(s) of concern?
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Contraindications
Non-surgical Body Contouring (Select all that apply)
Pregnancy or breastfeeding
Pacemaker or other implanted electronic devices
Metal implant(s) in the treatment area
Active cancer or history of cancer
Liver or kidney diseases
Uncontrolled diabetes or blood sugar issues
Active infections or skin conditions in the treatment area
Blood clotting disorders or use of blood thinners
Heart disease or cardiovascular conditions
Recent surgery (less than 3 months)
Lipedema
Recent Botox, cosmetic fillers or threads in the treatment area
Manual Lymphatic Drainage/Brazilian Lymphatic Drainage (Select all that apply)
Acute deep vein thrombosis (DVT)
Active infection or fever
Blood clotts
Congestive heart failure
Kidney failure or severe kidney disease
Active cancer (unless approved in writing by an acting medical director or oncologist)
Untreated lymphedema or severe swelling
History of lymph node removal in the treatment area
Less than 12 weeks post surgical
Recent Botox, cosmetic fillers or threads in the treatment area
Post-Surgical Care (Select all that apply)
Necrosis
Active infection or fever
Deep vein thrombosis (DVT)
Blood clotts
Lymphedema or severe swelling
Kidney failure or severe kidney disease
Recent Botox, cosmetic fillers or threads in the treatment area
Acknowledgement & Consent
I certify that the information provided is accurate and complete to the best of my knowledge. I understand that withholding or providing inaccurate information may affect the safety and effectiveness of my treatment. I acknowledge that certain medical conditions or circumstances may prevent me from receiving treatment, and I agree to discuss any concerns with staff at LymphAddict.
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I agree
I do not agree
I understand that all services are non-invasive and although side effects are uncommon, I may experience tenderness and/or bruising in the treatment area. I will notify the technician if I experience any discomfort during my treatment so pressure/frequency can be adjusted accordingly.
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I agree
I do not agree
I consulted with the technician and have realistic expectations about the type of results I can achieve. I understand that a minimum of 6-12 sessions are recommended for optimal results for body contouring services. I further understand that individual results vary and cannot be guaranteed. All sales are final and non-refundable.
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I agree
I do not agree
I understand that photos and/or videos may be taken both pre & post treatment for documentation purposes, and does not constitute consent to publish my likeness unless undersigned. I understand that my personal information will not be used in any publications without express written consent. I hereby grant LymphAddict permission to use my likeness in photograph or other digital reproduction in any and all of its publications, including website entries, social media and advertising without compensation or any other consideration.
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I agree
I do not agree
I confirm that I am 18 years of age or older, and am competent to contract in my own name. By signing this release, I hereby waive LymphAddict and its staff from any and all liability - past, present and future.
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I agree
I do not agree
Please sign below to confirm the accuracy of the provided information (Use your finger or a stylus pen)
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