LymphAddict Client Intake & Consent

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*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Permission to contact you via email for promotional purposes?*

YesNo
How did you hear about us? (e.g., referral, website, Instagram, Google, other)*
Current weight*
Please use pounds (lbs) not kilograms
Height*
Have you experienced any of the following health conditions past or present? (Select all that apply)*

NoneHeart disease or cardiovascular issuesHigh or low blood pressureDiabetes Type 1Diabetes Type 2Thyroid disordersAutoimmune disordersCancer (past or present)AIDS/HIVKidney or liver diseaseLymphedema or lymphatic system disordersLipedemaBlood clotting disordersSkin conditionsChronic pain or fibromyalgiaNeurological conditionsRespiratory conditionsCirculatory conditionsIrritible Bowel SyndromeHoromonal imbalances (PCOS, menopause, etc.)Spider veinsVaricose veins
Please specify any other health conditions or concerns not listed above.
Are you currently taking any medications or supplements?*

YesNo
Please list any medications, supplements, or treatments you are currently using.
Allergies or Sensitivities (Select all that apply)*

NoneLatexMedicationsTopical productsOther
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?*

YesNo
Do you have any areas of heightened pain or sensitivity?*

YesNo
Skin & Tissue Health (Select all that apply)*

NoneOpen wounds, cuts or burns in treatment areaActive infectionsRecent tattoo or piercing in the treatment areaScarring or keloidsOther
Do you have any current infections or skin conditions?*

YesNo
Please describe any current infections or skin issues.
Are you currently pregnant or breastfeeding?*

NoPregnantBreastfeedingTrying to conceivePostpartum (less than 12 months)
How would you describe your daily water intake?*

High (2+ litres)Moderate (1-2 litres)Low (under 1 litre)Dehydrated (under 500ml)
How often do you exercise?*

Daily3-5 times per week1-2 times per weekRarely/Never
Do you follow a specific diet (e.g., keto, vegan, gluten free, etc.)*

YesNoOther
Alcohol Consumption*

Non-drinkerOccasional/SocialFrequently
Smoking & Drug Use (Select all that apply)*

Non-smokerCurrent smokerFormer smokerCannabisVapeOther
How would you rate your current stress level?*

HighModerateLow
Approximately how many hours of sleep do you get per night?*
Which service(s) are you interested in? (Select all that apply)*

Non-surgical body contouringManual Lymphatic DrainageBrazilian Lymphatic DrainagePre or Post Surgical Care
What are your primary goals for treatment? (Select all that apply)*

Fat reductionSkin tighteningCellulite reductionColombian Butt LiftingDouble Chin/Jawline sculptingSculpting & definitionDetoxificationSwelling & inflammation managementPain reliefImproved circulationPost-surgical recoveryOther
Have you received any form of non-surgical body contouring, lymphatic drainage or post-surgical care in the past?*

YesNo
What are your area(s) of concern?*
File Upload

Feel free to upload an image of your area(s) of concern (optional)
Cancelof
Contraindications
Non-surgical Body Contouring (Select all that apply)

Pregnancy or breastfeedingPacemaker or other implanted electronic devicesMetal implant(s) in the treatment areaActive cancer or history of cancerLiver or kidney diseasesUncontrolled diabetes or blood sugar issuesActive infections or skin conditions in the treatment areaBlood clotting disorders or use of blood thinnersHeart disease or cardiovascular conditionsRecent surgery (less than 3 months)LipedemaRecent 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 feverBlood clottsCongestive heart failureKidney failure or severe kidney diseaseActive cancer (unless approved in writing by an acting medical director or oncologist)Untreated lymphedema or severe swellingHistory of lymph node removal in the treatment areaLess than 12 weeks post surgicalRecent Botox, cosmetic fillers or threads in the treatment area
Post-Surgical Care (Select all that apply)

NecrosisActive infection or feverDeep vein thrombosis (DVT)Blood clottsLymphedema or severe swellingKidney failure or severe kidney diseaseRecent 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.*

I agreeI 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.*

I agreeI 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.*

I agreeI 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.*

I agreeI 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.*

I agreeI do not agree
Please sign below to confirm the accuracy of the provided information (Use your finger or a stylus pen)*
Date*

MonthDayYear
Date
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Client Intake & Consent

Contraindications

Acknowledgement & Consent