MEDICAL CLEARANCE FOR LYMPHATIC DRAINAGE MASSAGE
To be completed by a licensed healthcare provider. This form authorizes a patient to receive lymphatic drainage massage based on medical evaluation.
IMPORTANT: This clinic is NOT a Certified Lymphedema Therapist (CLT) practice and does NOT provide medically prescribed lymphedema therapy. Services provided here are limited to general wellness manual lymphatic drainage (MLD) and related massage for non-acute, non-oncologic, and non-complex lymphedema cases. If your patient requires CLT-level care or medically supervised lymphedema management, please indicate that below and do NOT clear them for general wellness MLD at this clinic.
Patient Details
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Clearance
Medical Reason for Clearance
*
Provider Evaluation
Summary of Medical Evaluation
*
Specific Precautions
Precautions or Special Instructions
*
Provider Credentials & Authorization
Provider Full Name
*
First Name
Last Name
Medical Credentials or License Number
*
Provider Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Email Address
*
example@example.com
Date of Authorization
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Signature
*
Medical Clearance Status
*
Approved
Denied
Types of massage that are medically APPROVED for this patient:
*
General relaxation massage
Gentle manual lymphatic drainage (MLD)
Myofascial release (light to moderate)
Deep tissue massage (localized only)
No massage techniques involving deep pressure
Other
Body areas where massage is APPROVED:
*
Neck and shoulders
Upper back
Lower back
Arms and hands
Legs and feet
Abdomen
Gluteal area (non-BBL, non-surgical)
Surgical areas (only as described in instructions below)
No massage on or near surgical sites
Other
Maximum pressure level allowed:
*
Light only
Light to moderate
Moderate
Deep pressure allowed in non-surgical areas
No pressure beyond gentle skin-stretch
Specific massage techniques or modalities that are NOT allowed:
*
Submit Clearance
Submit Clearance
Should be Empty: