Manual Lymphatic Drainage Intake Form -

Name

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Date of Birth*

In Case of Emergency*

Phone*

Name of Primary Care Physician and Clinic*

For what reason are you seeking Manual Lymphatic Drainage?*

Medical reason
Relaxation

If you are here for a medical issue, when did the problem start?

Please describe your problem including where it is and its severity.*

In order to create the most beneficial session, please mark all current and previous conditions that apply. If none apply, select other and write n/a.

Please list all surgeries (including Cesarean section).

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Surgery	Date	Hospital and Surgeon

Please list all medications (including vitamins, hormones, and herbs) and reason for prescription.

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Medication	Reason

Is there is anything else that your MLD therapist should know about you or your needs before the session?*

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. I further understand that massage or bodywork should not be construed as a substitute for medical examination, 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. *Please Note: Manual Lymphatic Drainage (MLD) is a very powerful modality and certain medical conditions are contraindicated and determine if and when you can receive a session. After the consultation and review of the information you have provided on this form, it will be determined if MLD should be administered to you today. Some conditions will require a note from your doctor before proceeding. Please understand this is for your safety and well-being.

I,*

Consent to Treatment of Minor: By my signature below, I hereby authorize Carmela Wiese, LMT, to administer Manual Lymphatic Drainage techniques to my child or dependent as they deem necessary. Signature of Parent or Guardian