Electro-Lymphatic New Client Paperwork

CLIENT INFORMATION:

Name:

Today's Date:

Home Phone Number:

Cell Phone Number:

Email:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate:

Age:

Referred by:

Name of Primary Care Physician:

In Case of Emergency, please contact:

Emergency Contact Name:

Emergency Contact Phone Number:

Relationship:

PERSONAL HEALTH & HISTORY:

For what reason are you seeking Electro-Lymphatic?

Therapeutic
Medical Issue
Other

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

Please describe your problem, including where it is and its severity:

List any medications you are taking, including hormones, vitamins, herbs, and nonprescription medications:

List any surgeries you have had, and their reason and approximate date:

CLIENT CONSENT TO UNDERGO ELECTRO-LYMPHATIC

I understand and consent to the following:

Please understand that in answering questions, we do not diagnose or prescribe, but offer information only to help you cooperate with your doctor in your mutual problem of building health. In the event that you use this information without your doctor’s approval, you are prescribing for yourself which is your constitutional right, but the Well of Life Center for Holistic Healthcare, LLC through its clinicians, employees, and/or independent contractors collectively “Well of Life”) assume no responsibility.

I state that I am over 18 years of age, and I am in general good health.

By typing my name above, I authorize the Well of Life Center for Holistic Healthcare to perform the Electro Lymphatic Therapy session. I am doing this therapy, knowing that there are no guarantees, as none have been expressed or implied. Typing my name in the box acts as my signature on this page and absolves any liability on behalf any therapists of the Well of Life Center or any of their assigns, at this present time or any time in the future.

CONTRAINDICATIONS FOR ELECTRO-LYMPHATIC:

Please initial each line that you do NOT have any of the following contraindications.

I do not have an electronic device such as a pacemaker.
I have not had surgery or an organ transplant.
I do not take blood thinner.
I am not pregnant.
I do not have major cardiac problems.
I am not on life support.
I do not have rods or pins, head coils, staples, or stunts.
I do not have hemorrhaging or bleeding.

Electro-Lymphatic Informed Consent and Liability Release Form and Agreement and Release of Liability:

Please click HERE to read our Electro-Lymphatic Informed Consent and Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of the Electro-Lymphatic Informed Consent and Liability Release Form and Agreement and Release of Liability.

WELL SPA

New Client Appointment Checklist

Remove dentures

No jewelry

No makeup, perfume, lotions, or deodorants

No shaving/waxing for 24 hours prior to session

No food 2-4 hours prior to session

Contraindications

An electronic device such as a pacemaker

Have had surgery or an organ transplant, until consulting a physician to make sure the body has adapted to these altered changes

Are on a blood thinner

Currently pregnant

Major cardiac problems

On life support, has rods or pins, head coils, staples, or stunts

Hemorrhaging or bleeding

Please note…

CLIENT INFORMATION:

In Case of Emergency, please contact:

PERSONAL HEALTH & HISTORY:

CONTRAINDICATIONS FOR ELECTRO-LYMPHATIC:

Contact Us

Hours

Well of Life Center for Holistic Healthcare

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