• MLD Intake Form

    Manual Lymphatic Drainage intake for Massage with Annika. Please complete the screening, history, lifestyle, and consent sections.

  • Personal Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Reason for Visit & Goals

  • Have you had MLD before?*
  • Was it beneficial?

  • Contraindications

  • Active infection
  • Fever
  • Cellulitis
  • Deep vein thrombosis (DVT)
  • Congestive heart failure
  • Kidney disease
  • Active cancer treatment
  • Shortness of breath
  • Recent vaccination

  • Stomach Conditions

  • Do you currently have, or have you ever been diagnosed with:

  • Medical Conditions

  • Heart disease*
  • Liver disease*
  • Diabetes*
  • Thyroid disorder*
  • Autoimmune condition*
  • Neurological condition*
  • Blood clotting disorder*
  • Blood pressure concerns*

  • Swelling & Lymphatic History

  • Do you have swelling or lymphatic issues?*
  • Lymphedema
  • Lipedema
  • Compression garments

  • Surgical History

  • Have you had any surgeries?*
  • Lymph node removal

  • Cancer History

  • History of cancer?*

  • Skin & Tissue Health

  • Skin and tissue conditions

  • Medications & Allergies

  • Currently taking any medications?*
  • Blood thinners*
  • Diuretics*
  • Steroids*

  • Lifestyle

  • Miscellaneous

  • If lymphatic work to the breast tissue is deemed necessary as part of your treatment, do you consent to the area being appropriately exposed and treated?
  • How did you hear about me?

  • Consent & Signature

  • I understand that Manual Lymphatic Drainage is a complementary wellness service and is not a substitute for medical diagnosis or treatment.I understand that it is my responsibility to inform my practitioner of any changes in my health status. I have disclosed all known medical conditions relevant to my care.I voluntarily consent to receive Manual Lymphatic Drainage treatment.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  •  


    Liability Waiver


    I ____________________understand that the manual lymphatic drainage (MLD) I receive is provided for the basic purpose of improving the flow of the lymphatic system and/or for relaxation. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so the session may be adjusted or stopped 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 I should seek a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork/hands on treatment practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness, and that nothing said in the course of our session or pertaining to our session currently or in the future given should be construed as such. Certain medical conditions are contraindicated and determine if and when you can receive a session. After the consultation and review of the information provided, it will be determined if MLD should be administered. Some conditions will require a note from a physician before proceeding.  


    Because massage/body work should not be performed under certain medical conditions, I affirm that I have stated all 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 now or in the future. 


    Given the above, I understand that response to treatment varies on an individual basis and that specific results are not guaranteed. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmless and release from any and all liability Massage with Annika and the individual that provided my treatment, the insured, and any additional insureds, as well as any officers, directors, or employees of the above companies for any condition or result, known or unknown, that may arise as a consequence of any treatment that I receive.


    I have fully disclosed on my client intake form any medications, previous complications, or current conditions that may affect my treatment. I understand and agree that any legal action of any kind related to any treatment I receive will be limited to binding arbitration using a single arbitrator agreed to by both parties.


    The client indicated below also agrees to forever hold harmless and release Massage with Annika from any and all liability, claims, or demands of any kind or nature related to the transmission of any disease, condition or illness they may allege to have contracted or been exposed to as the result of any treatment, person, or visit at the insured’s location.


    My practitioner has answered any/all questions. I have read and understood the following information and is signing this under my own free will. My practitioner will provide me with a copy of this form upon my request

     

     

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  •  

    Policy Notification


    Thank you for choosing Massage with Annika as your massage and bodywork provider. In order to provide the best service possible to my clients, I have implemented the following policies:


     Cancellation & No Show Policy

     I require at least 24 hours notice to cancel an appointment. Clients who cancel an appointment with less than 24 hours notice will be billed the price of the scheduled service. If I am able to reschedule the allotted time with a new appointment, that fee will be waived. Clients who do not show up/are not home for a scheduled appointment or do not notify me in advance will be billed for the full price of the scheduled service. I understand that emergencies and illnesses can arise, therefore last minute cancellations due to things such as verifiable emergencies, illnesses or inclement weather will generally not result in any missed session charges, however this is to be determined at the practitioner's discretion. Absolutely no refunds will be provided after the service has been completed and paid for. 


    Massage Termination 

    Only professional massage, lymphatic, and bodywork services for relaxation or therapeutic purposes are offered at this massage practice. Massage services will be terminated immediately in the event of inappropriate conduct of any kind. This includes harassment, threatening speech or behavior, sexual advances or requests, or disrespectful actions or language. A session will not be conducted if the client is under the influence of drugs or alcohol. If the massage is terminated for any of these reasons, full payment for the scheduled session is still required.


     Draping Policy

     Clients will be appropriately draped with a sheet and/or towel at all times during their massage. Only areas of the body that are currently being treated will be exposed. The breast and genital areas will always remain draped and are never massaged unless certain medical needs specify otherwise.


    Signing below indicates that you have read, understood, and will abide by the massage policies indicated above. 

     

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: