Massage Services & Post Surgical Manual Lymphatic Drainage (MLD) Client Intake Form

  • Massage Services & Post Surgical Manual Lymphatic Drainage (MLD) Client Intake Form

  • Format: (000) 000-0000.
  • Date of Birth*
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  • Format: (000) 000-0000.
  • If you are here for Post OP massage, have you ever had MLD-massage before?*
  • If yes, date of last MLD
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  • Other types of massages experienced*
  • Level of pressure you prefer*
  • Image field 20
  • Please review this list. Check those that have affected your health recently or in the past for SKIN RELATED conditions*
  • Past history of illnesses. Check all that apply.*
  • Are you currently undergoing any cancer treatments?*
  • If yes, date of last chemotherapy treatment?
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  • Are you currently pregnant?*

  • By signing below, you agree to the following;

     

    I have completed this form to the best of my ability and knowledge. I agree to inform my therapist if any of the above information changes at any time.

  • Today's Date*
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  • Should be Empty: