LYMPHATIC DRAINAGE MASSAGE PRE-SCREENING & CONSENT FORM
Please complete this safety screening before your appointment request can be approved. Because lymphatic massage significantly accelerates fluid circulation throughout your body, it affects your entire circulatory system. For your complete safety, we must review your health history before performing this service.
Client Information
Full Name
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Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Core Purpose of Session
What is the primary reason you are seeking Lymphatic Massage?
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General Wellness / Relaxation / Immune Support
Post-Surgical Recovery (Lipo 360, Cosmetic Surgery, etc.)
Other
Absolute Safety Screening
🚫 DO YOU CURRENTLY HAVE, OR HAVE YOU BEEN DIAGNOSED WITH, ANY OF THE FOLLOWING CONDITIONS? (Check all that apply)
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Active Blood Clots, Deep Vein Thrombosis (DVT), or Phlebitis
Congestive Heart Failure (CHF) or unmanaged heart conditions
Kidney Failure or Severe Renal Insufficiency
Active Infection or Fever (within the last 72 hours)
Active Malignant Cancer / Undergoing active oncology treatment
Brazilian Butt Lift (BBL) surgery recovery
None of the above
Post-Surgical Details (Only if applicable)
Type of Surgery & Date Performed (e.g., Lipo 360 on MM/DD/YYYY)
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Have all of your surgical drains and tubes been fully removed?
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Yes, all drains are out.
No, I still have active drains/tubes.
Not applicable (Wellness client).
Did you experience any post-operative complications (such as lipo burns, incision failure, blood transfusions, necrosis, or hematomas)?
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No complications.
Yes (If yes, a formal physician release will be required prior to approval).
Not applicable.
Client Consent & Liability Acknowledgement
Important Information About Post-Surgical Lymphatic Care
This clinic provides general lymphatic drainage massage for wellness and recovery support only. If your surgeon or medical team recommended post-surgical lymphatic drainage or a Certified Lymphedema Therapist (CLT), you likely need a different, medically specialized service. Booking here instead of with a CLT or prescribed provider may delay proper medical care. Sometimes surgeons do explain this, but clients may not realize that post-surgical lymphatic therapy with a CLT is different from the general lymphatic massage offered in this clinic. If you are unsure, please contact your surgeon or medical team before booking here.
Has your surgeon or medical team recommended post-surgical lymphatic drainage or a Certified Lymphedema Therapist (CLT) for you?
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Yes – I was advised to see a CLT or post-surgical lymphatic specialist. I understand this clinic is not the appropriate provider for that service.
No – I was not given that recommendation.
I’m not sure / it wasn’t clearly explained.
Does not apply (General Wellness client)
Please confirm you understand the type of service offered at this clinic:
Client Initials (Acknowledgement)
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Please read and initial the following terms: 1. I understand that the massage therapist does not perform BBL lymphatic drainage, and does not push fluid out of open incisions or drainage tubes. 2. I understand that if I have a history of blood clots/DVT, heart conditions, kidney issues, or post-surgical complications, I will be required to provide a formal medical clearance form from my physician before my appointment can be confirmed. 3. I agree that I am not currently under the influence of heavy medications, drugs, or alcohol, and will remain coherent for the entire session. 4. I understand that failure to disclose accurate medical information regarding my surgery or general health history will result in the immediate termination of services.
Client Initials
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Client Electronic Signature
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Date Signed
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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