OCL Client Intake & Registration

Client History & Registration Form

Please complete all sections of this form accurately. Your information is confidential and helps us provide the best care.
Personal Information
Full Name

First NameLast Name
Date of Birth

DayMonthYear
Date
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Height:
cm
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to You
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Team
Referred by:
General Practitioner (GP):
GP Clinic Name:
Surgeon (if applicable):
Nursing Team (if applicable):
Medical History
Please tick any conditions that apply to you, either currently or in the past.
If you selected Other or any of the above, please provide details.
Medications
Please list all current medications, including dosage, what they are prescribed for and when you take them.
Lifestyle & Physical Activity
Is this your first massage or manual lymphatic drainage treatment?
Do you participate in regular physical activity? Please include the type of activity, frequency and intensity.
Today's Appointment
What brings you in today?
Areas requiring treatment:
Surgery History
Have you recently undergone surgery or are you scheduled for surgery?
If yes, please provide details.
Date of surgery:

DayMonthYear
Date
Were there any complications?
If yes, please describe.
Photography Consent
Clinical photographs may be taken to document treatment progress.

Your identity will remain confidential wherever reasonably possible. Identifying features such as tattoos, nipples and the genital/pubic region will be obscured or excluded where appropriate.

Your decision regarding photography will not affect the care you receive.
Please select one option:
Privacy, Terms & Conditions
I acknowledge that:
- the information I have provided is true and complete to the best of my knowledge;
- Open Circuit Lymphatics will collect, store and use my personal information in accordance with applicable privacy legislation;
- I understand that appointments cancelled or rescheduled with less than 48 hours notice may incur a cancellation fee;
- I have read and agree to the clinic's Terms & Conditions, including payment, cancellation and privacy policies.
Terms & Conditions are available at:

https://www.opencircuitlymphatics.com.au/terms-conditions
Declaration & Consent
I declare that the information I have provided is accurate and complete.

I understand and agree that:
- Massage therapy, manual lymphatic drainage and associated treatments are provided to support wellbeing, recovery and symptom management and are not a substitute for medical care.
- I have disclosed all relevant medical conditions, medications and other health information and will inform my therapist of any changes to my health.
- I understand the nature of the treatment being provided and voluntarily consent to receive treatment from Open Circuit Lymphatics.
- While every effort will be made to provide safe and effective treatment, no guarantee of treatment outcomes can be made.
- I may stop treatment or withdraw my consent at any time.
Full Name

First NameLast Name
Signature
Date

DayMonthYear
Date
Questions or concerns? Our team is here to help.

Please contact Open Circuit Lymphatics if you require clarification about your treatment, this form, or our policies.

Phone: 0420 767 690
Email: opencircuitlymphatics@gmail.com
Website: www.opencircuitlymphatics.com.au
Should be Empty:

Client History & Registration Form

Personal Information

Emergency Contact

Medical Team

Medical History

Medications

Lifestyle & Physical Activity

Today's Appointment

Surgery History

Photography Consent

Privacy, Terms & Conditions

Declaration & Consent