Post Op Intake Form

Criselda White, CCST, CMLDT, CLT/CDT, MTI, LMT TX #MT129702 - Massage Instructor

910 Quest Pkwy, Suite 6, Cedar Park, TX 78613 (512) 817-3008 I cris@movinglymphinmotion.com www.movinglymphinmotion.com

Post-Operative Massage Intake & Consent Form

Full Name

Date of Birth

Date

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Emergency Contact & Phone

Format: (000) 000-0000.

Date of Surgery

Date

Type of Procedure eg Lipo BBL Tummy Tuck etc

Surgeons Name Clinic

Do you have any surgical drains? Yes No

If yes how many and where are they located

Are you wearing compression garments or foams? Yes No

Current Post-Op Symptoms & Conditions

Pain or tenderness

Bruising or discoloration

Hardness or lumps fibrosis

Drainage from incisions

Numbness or tingling

Fever or signs of infection

Shortness of breath

Other please specify

Please explain any conditions checked above

Goals for Treatment What are your primary goals for receiving post-op lymphatic massage? (Check all that apply)

Reduce swelling

Minimize fibrosis and scar tissue

Improve lymphatic drainage

Support immune response and healing

Relieve pain and discomfort

Improve body contour results

Prevent complications

Other

Consent & Authorization I understand that post-operative massage therapy is intended to support the healing process and reduce swelling after surgery. I confirm that my surgeon has approved massage as part of my recovery plan. I affirm that I have disclosed all known medical and surgical information and agree to keep the therapist updated about any changes. I understand that if any signs of complications

arise (such as infection, open wounds, or blood clots), the therapist may delay or refuse treatment and refer me to a physician.

Client Signature

Date

All services are non-refundable once rendered. If you cancel your appointment at least 24 hours in advance, you may reschedule your session at no additional charge. Prepaid sessions or packages are not refundable but may be transferred to another person with written permission.

If you miss your appointment without notice (No-Call/No-Show), you will be charged 100% of the session fee. Repeated violations may result in refusal of future services. If you are running late, please call or text as a courtesy. More than 15 minutes late without notice will be considered