Well of Life Center for Holistic Healthcare

Manual Lymphatic Drainage Paperwork

New Client Appointment Checklist

5

Please read through this in its entirety and review contraindications

5
Drink at least 16 oz. of water prior to your appointment
5
Complete and submit form below
5
Wear loose fitting clothing (no sweaters or turtlenecks)

These guidelines are in place for your protection and ours, as we strive to serve you to the best of our ability.

Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced.

Please contact our Client Advocate if you have any questions or need additional information.

Contraindications

Is there anyone who should not use MLD?

If any of the below apply and you would like to cancel your appointment, please contact our Client Advocate.

Contraindications for MLD:
Chemotherapy (MLD can be done after two weeks of a completed Chemotherapy treatment); heart, kidney, or liver failure; malignant tumor; deep vein thrombosis; medically-diagnosed infection; open wounds; prescription blood thinners.

Contraindications for Pregnancy MLD:
High risk pregnancy; malignant tumor; acute inflammation; deep vein thrombosis; heart, kidney, or liver failure; kidney disease; morning sickness.

New Client Form

CLIENT INFORMATION:

In Case of Emergency, please contact:

PERSONAL HEALTH & HISTORY:

Please mark all CURRENT symptoms:

Please mark all PAST conditions:

PLEASE READ THROUGH THE FOLLOWING CONTRAINDICATIONS FOR MANUAL LYMPHATIC DRAINAGE BEFORE SIGNING OUR AGREEMENT AND RELEASE OF LIABILITY. If any of the below apply and you would like to cancel your appointment, please contact our Client Advocate. Contraindications for MLD: Chemotherapy (MLD can be done after two weeks of a completed Chemotherapy treatment); heart, kidney, or liver failure; malignant tumor; deep vein thrombosis; medically-diagnosed infection; open wounds; prescription blood thinners. Contraindications for Pregnancy MLD: High risk pregnancy; malignant tumor; acute inflammation; deep vein thrombosis; heart, kidney, or liver failure; kidney disease; morning sickness.

CLIENT CONSENT

Please click HERE to read our Manual Lymphatic Drainage 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 Manual Lymphatic Drainage Informed Consent and Liability Release Form and Agreement and Release of Liability.

Pin It on Pinterest