Name
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First Name
Last Name
Email
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Phone
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(###)
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birth Date
MM
DD
YYYY
Medications
Existing Medical Conditions
Allergies
1. Cause of Concern or Injury
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2. How Long Since First Noticed
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3. Describe Your Treatment Goals
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Describe briefly what symptoms you're experiencing and where.
4. Past Treatment
Enter treatment information here.
5. Manual Lymphatic Drainage Massage (MLD): What Was the Nature of Your Surgery?
6. Manual Lymphatic Drainage Massage (MLD): If You're Post-Op, By How Many Weeks?
I'm not post-op
Less than 1 week
1 week
2 weeks
3 weeks
4 weeks
5 weeks
6 or more weeks
7. Manual Lymphatic Drainage Massage (MLD): If You're Post-Op, Are You Unable to Lie Comfortably On Your:
8. Manual Lymphatic Drainage Massage (MLD): If You're Post-Op, Please Provide the Name of Your Surgeon:
9. Manual Lymphatic Drainage Massage (MLD): Please note that this treatment uses light pressure for safe, sanitary, and comfortable swelling reduction, will not open incisions or push fluid out, and uses no machines or tools.
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N/A
I understand
10. Please note that appointment confirmations are sent through email, text message, or both. If you have not received an appointment confirmation for your treatment within 5 minutes, please contact us.
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I understand
11. Please note that a valid credit card on file is required to hold all appointments. Cancellations must be made 24 hours in advance to avoid a 100% cancellation fee. No-call no-show appointments will be charged a 100% fee. Anyone arriving over 20 minutes late for an appointment will be marked as a no-call no-show.
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I understand
12. COVID-19 Precautions
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Please take a moment to read the following information:
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· I understand/agree that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
· If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort.
· I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
· I understand/agree that the services offered today are not a substitute for medical care. I understand/agree that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.
· I affirm that I have notified my therapist of all known medical conditions and injuries.
· I agree to inform the therapist of any changes in my health and medical condition. I understand that there shall be no liability on the therapist’s part should I forget to do so.
· I understand/agree that massage is entirely therapeutic and non-sexual in nature, that inappropriate behavior will result in immediate cancellation of current and future sessions, and that I will be billed for the full cost of the treatment service.
· I understand/agree that I am not entitled to full appointment time if I arrive late, but may receive remaining appointment time at my therapist's discretion.
· I understand/agree that my appointment may be marked as a no-call no-show and/or canceled if I am more than 20 minutes late.
· I understand/agree that no-call no-show appointments are non-refundable.
· I understand/agree that services are non-refundable once rendered, and packaged treatments and gift cards are ineligible for rebates or refunds once purchased.
· By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.
Today's Date
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MM
DD
YYYY
