Lymphatic Drainage Massage Client Intake Form

Please complete the following details prior to your first session.

First Name

Last Name

Address

Street Address

City

State

Country

Postal code

Email *

Phone *

Emergency Contact Details

Occupation *

Date of birth *

Please list any allergies/sensitivities

List any medications & /or supplements you currently take

GP Contact Details *

Reason for Treatment?

Have you ever received MLD treatment before? *

If yes, how recent?

Within a month

Within 3 months

What are your areas of concern? *

*Other pertinent medical factor not included above

Rate your stress levels *

Low

Moderate

High

Rate your physical activity *

Low (sedentry)

Occassional

Active

How did you hear about Holistic Grace? *

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive massage services - specifically MLD.
2) I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.
3) I understand that Holistic Grace (referred to as HG going forward) does not diagnose illnesses or injuries, or prescribe medications.
4) I have clearance from my physician to receive massage therapy.
5) I understand the risks associated with massage therapy that include, but are not limited to temporary exacerbation of symptoms/pain. I, therefore, release HG from all liability concerning these symptoms that may occur during or post session.
6) I understand the importance of disclosing all pertinent medical conditions and medications I am taking.
I understand that there may be additional risks based on my physical condition.
7) I understand that it is my responsibility to inform HG of any discomfort I may feel during the session so that adjustments can be made accordingly.
8) I understand that I or HG may terminate the session at any time and that poor conduct will not be tolerated by either parties.
9) I understand that to cancel my session, notice of 12hrs or more must be given.

By checking this box, I acknowledge the above and give consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. You may opt out at any time.

Attach consent forms as necessary

Browse Files

Signature *

Clear

Date *

If you have any questions or concerns please do contact me.

The information shared in this document will remain confidential & will not be used for any marketing.

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