Intake Form | Lymphatic Specialists of Madison

Personal Information

First Name *

Last Name *

Phone (day) *

Phone (evening)

Email *

Date of Birth *

What are your pronouns?

Street Address *

Address Line 2

City *

State *

ZIP Code *

Country *

In Case of Emergency

Emergency Contact *

Phone *

Primary Care Physician and Clinic *

How Did You Hear About Us?

Reason for Seeking Manual Lymphatic Drainage Massage

For what reason are you seeking Manual Lymphatic Drainage Massage? *

Medical reasonRelaxationOther

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

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

Medical Conditions

Surgeries

Please list all surgeries (including Cesarean section).

Medications

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

Additional Information

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

Consent and Understanding

I understand that the Manual Lymphatic Drainage Massage/scar tissue work I receive is provided for the basic purpose of improving the flow of my lymphatic system, to prevent scar tissue adhesions, increase scar tissue mobility 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, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that the practitioners at Lymphatic Specialists of Madison operate within the scope of their individual professional licenses and credentials. As such, they are not authorized to provide medical diagnoses or offer recommendations regarding imaging or medications. Any information shared during a session that falls outside a practitioner's professional scope should not be interpreted as medical advice. Because MLD/scar tissue work 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 Massage (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 understand and agree to the above terms *

Consent to Treatment of Minor

By my signature below, I hereby authorize practitioners at LSOM to administer Manual Lymphatic Drainage techniques to my child or dependent as they deem necessary.

Signature of Parent or Guardian

Manual Lymphatic Drainage Massage Intake Form

Personal Information

In Case of Emergency

How Did You Hear About Us?

Reason for Seeking Manual Lymphatic Drainage Massage

Medical Conditions

General *

Ears, Nose, Throat *

Cardiovascular *

Gastro-Intestinal *

Urinary *

Female Reproductive*

Musculoskeletal *

Skin *

Hematologic/Lymphatic *

Neurological *

Allergies *

Emotional *

Surgeries

Medications

Additional Information

Ready to Get Started?