Intake | OC Lymphatics

First name

Preferred name

Last name

Email

Phone

Date of birth

Month

Day

Year

Emergency contact phone number and name

Medical history and allergies

Please select all that apply to help us provide appropriate care and accommodation.

Details regarding medical history

Please provide details regarding reason for visit. For post-surgical treatment, please describe all surgeries performed, date(s) and name of surgeon.

Liability Acknowledgment: By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business (OC Lymphatics), its owner, and its staff from any and all liability, past, present, and future, relating to the services provided.

Medical Information Consent: I certify that I have received clearance from my physician to receive manual lymphatic drainage (MLD) and any accompanying related services. I give my therapist and OC Lymphatics permission to discuss any pertinent information regarding my medical history with my physician/medical team as it pertains to my care. I have notified my therapist of all known medical conditions and injuries, and will notify my therapist of any changes in my health and medical condition.

Signature

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Intake Form & Liability Waiver