MLD Client Intake
Please fill out at least 24 hours before your session
Name
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First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Age
*
Birth Date
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Month
-
Day
Year
Date
Sex
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Male
Female
Occupation
HOW DID YOU HEAR ABOUT US? PLEASE BE SPECIFIC. IF A FRIEND/FAMILY MEMBER/DOCTOR/INSTAGRAM FRIEND/ETC. REFERRED YOU TO US, TELL US THEIR NAME! WE OFFER PERKS TO THOSE WHO REFER US, SO PLEASE, HELP US GIVE CREDIT WHERE CREDIT IS DUE.
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Emergency Contact
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Relationship
*
Have you ever received Manual Lymphatic Drainage (MLD)? And if so, when?
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Other types of bodywork received?
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What are your goals for this session?
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For Clients With a Caner Diagnosis Only
Skip down to the next section if not applicable
What was your diagnosis?
Are you currently undergoing cancer treatment?
Yes
No
Radiation
Yes
No
Date of last treatment
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Month
-
Day
Year
Date
How many radiation sessions have you had?
How many are recommended?
Chemotherapy
Yes
No
Date of last treatment
-
Month
-
Day
Year
Date
How many sessions have you had?
How many are recommended?
Do you have written permission from your treatment team to receive MLD at this time?
Yes
No
Do you give written permission to contact your treatment team for permission to receive MLD at this time?
Yes
No
If yes, please provide contact information
Please describe the full procedure and if there were any complications.
Were drains used in the procedure?
Yes
No
If yes, how many?
Have drains been removed?
Yes
No
Are surgical sites healed?
Yes
No
WEre any lymph nodes removed?
Yes
No
If yes, from what location(s) and how many?
For Clients Who Have Received Cosmetic Surgery Procedures:
Did your surgeon recommend post-surgical MLD?
Yes
No
Have you been cleared by your doctor to receive MLD?
Yes
No
Do you give permission to contact your doctor for written permission to receive MLD at this time?
Yes
No
If yes, please provide contact information
Have your recieved MLD after surgery?
Yes
No
Number of sessions
Are you in pain?
Yes
No
If yes, where?
Are you experiencing swelling or bruising?
Yes
No
If yes, where?
Please Mark ALL Surgeries/Procedures
Liposuction
360
Abdomen
Waist/Flanks
Arms
Hips/Buttocks
Back
Thighs
Inner Knees
Calves/Ankles
Neck/Chin
Breast
Augmentation with fat trasfer
Augmentation with implant
Lift
Removal
Implant Revision
Revision
Nipple Removal
Nipple Reconstruction
Breast Reconcstruction
Expanders
Areola Removal
Areola Reconstruction
Neck and Face
Face Lift
Rhinoplasty
Eyes/Brows
Cheek Augmentation
Neck/Chin
Body Lifts
Arm Lift
Body Lift
Body Contouring
Abdominoplasty
BBL
Hip Augmentation
Did you have any issues with blood clots or clotting?
Yes
No
Were drains used following the procedure?
Yes
No
Have all drains been removed?
Yes
No
Were you in a compression garment?
Yes
No
Are you wearing post-surgical garments?
Yes
No
Are you noticing thickening or fibrosis?
Yes
No
Please provide all the details of your recent surgery (date, hospital/clincic, surgeon)
Please list ALL medications and reason for taking them. Please note if the medication is related to the surgery.
Please Describe and Provide Dates
Prior Surgeries
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Auto Accidents
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Falls/Injuries
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Pregnancies
Are you currently pregnant?
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Yes
No
Health History
Please check all that apply
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Acute Infections/Cellulitis
Renal Failure
Cardia Edema/Chronic Heart Failure
Acute Deep Vein Thrombosis
Acute Bronchitis
Malignancies
Bronchial Asthma
Hypertension
Carida Arrhythmias
Sensitive Carotid Sinus Syndrome
Hyperthyroidism
Hypothyroidism
Stroke
Atherosclerosis
Carotid Endarterectomy
Dysmenorrhea
Illeu
Diverticulosis/Diverticulitits
Aortic Aneurysm in abdominal region
Crohn's Disease
Ulcerative Colitis
Recent Abdominal Surgery (within 1 year)
Radiation Fibrosis/ Radiation Cystitis
Unexplained Abdominal Pain
Post DVT Abdominal Area
Peripheral Arterial Disease
Spasticity
Raynaud's Disease
Paresis/Paralysis/Decreased Sensation
Malignant Lymphatic System
Reflex Sympathetic Dystrophy
Complex Regional Pain Syndrome
None of the above
Is there anything else that your theraphist should know before your session?
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Policies, Terms & Conditions
I understand that the Manual Lymphatic Drainage I receive is provided for the basic purpose of improving the flow of my lymphatic system and also for relaxation. IF I EXPERIENCE ANY PAIN OR DISCOMFORT DURING THIS SESSION, I WILL IMMEDIATELY INFORM THE PRACTITIONER SO THAT THE PRESSURE AND/OR STROKES MAY BE ADJUSTED TO MY LEVEL OF COMFORT.
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I Agree
I further understand that massage or bodywork should not be construed as a substitute for medical examinations, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my 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.
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I Agree
Please Note: It is important that you complete this intake in full. MANUAL LYMPATIC DRAINAGE (MLD) IS A VERY POWERFUL MODALITY AND CERTAIN MEDICAL CONDITIONS ARE CONTRAINDICATED AND DETERMINE IF OR WHEN, YOU CAN RECIEVE A SESSION. After the consolation and review of the information you have provided on this form, it will be determined if MLD should be administered to you. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being.
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I Agree
SALCEDO HEALTH RESERVES THE RIGHT TO REFUSE, POSTPONE OR TERMINATE TREATMENT WHENEVER WE DEEM IT IN THE BEST INTEREST OF ONE OR MORE OF THE PARTIES.
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I Agree
Other
RELEASE OF RECORDS/PERMISSION TO COMMUNICATE CONSENT I hereby give Salcedo Health consent to communicate with any and all practitioners involved in my treatment as they deem necessary.
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I Agree
I do forever release Salcedo Health LLC and their insurers, their respective officers, directors, stockholders, successors, employees, contractors and agents from all liability of any nature whatsoever, whether past, present, or future for any injury or damage which may occur to myself or my family as a result of my receiving massage therapy and bodywork from this point forward. I agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal or administrative action that has arisen or may arise directly or indirectly out of my participation in this therapy. I have completed this health form to the best of my knowledge. By agreeing to and submitting this form, I agree to abide by the polices, terms and conditions set forth and I realize these policies may change at any time without notice.
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I Agree
CANCELLATION/RESCHEDULING POLICY If I am not able to make a scheduled appointment, I agree to cancel or reschedule the appointment AT LEAST 24 hours in advance. I agree to pay $60 or 50% of the full session rate (whichever is greater) if I give less than 24 hours' notice. I agree to pay the full session rate if I give 2 hours' notice or less, or if I miss an appointment without giving notice. If I have a contagious illness, or have a sudden, unplanned health or personal emergency that will cause me to miss my appointment I agree to inform Salcedo Health immediately and agree to pay the cancellation fee unless Salcedo Health decides to grant an exception to my circumstance. I understand that payment is due at the time of service.
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I Agree
Submit
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