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Lymph Lyft Intake

Lymphatic Drainage & Bodywork
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    Client Intake Form

    All information is held in strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

    Simply type NA for anything that doesn’t apply to you.

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    • Afghanistan
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    • Rwanda
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    • Trinidad and Tobago
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    History of Pathology

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    If yes, please explain.
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    Lymph Lyft Policies:

    Client services and chart information are confidential. Written authorization is required from you to release any information.

           • Please turn off your cell phone for optimal relaxation

           • 24 hour cancellation notice is required to avoid being charged for your session but can be waived if sick due to Covid and always happy to accommodate schedule changes if possible 

           • You will be draped and at no time will genitalia be exposed. Breast tissue exposed only by request of client for medical purposes.

           • I understand that my therapeutic massage therapist or I may end the session at any time for any reason

           • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

     

    Client Agreement:

    I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

    I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

    It is my choice to receive therapeutic massage as a form of therapy.

    I understand that treatment given is designed to address the care and prevention of lymphatic stagnation, tension and fascia constrictions.

    I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust. 

    I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

    I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Lymph Lyft and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

    By my electronic signature below, I agree to the massage policy and client agreement above. 

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