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Consultation Form - BRAZILIAN Lymphatic Drainage

Please fill out the following form in order to see if Lymphatic Drainage is suitable

First Name

Email

Doctors Name

Have you been hospitalized in the last 12 months? *

No

Yes

Are you recovering from Surgery or Cancer treatment *

No

Yes

Last Name

Date of Birth

Doctor phone number

Are you suffering from a medical condition, illness, or injury?

No

Yes

Any form of infection, disease or fever in the last 2 weeks

No

Yes

Please select any that apply:

Undiagnosed Lump or awaiting results *

Heart Conditions/ Thrombosis/ Phlebitis / Heart attack*

Acute Inflammation*

Cancer/ Melanoma in the last 5 years *

Tubercolosis*

Malignant melanomas*

Diabetes

Are you pregnant

Are you menstruating

Diarrhoea or Vomiting

High Blood pressure

Low Blood pressure

Fibromyalgia

Kidney issues

Asthma

Epilepsy

Oedema **** Is it a result of Heart and Kidney Disease

Hyperactive Thyroid

Arthritis

Any other condition being treated by GP or other complementary practitioner?

Removal of spleen

Implants

Joint Replacements

Liver issues

Heart disease

Neuropathy

If you answered yes to any question, please elaborate

I declare that the info I’ve provided is accurate & complete and that I am responsible for checking with my doctor if the session is suitable for me

I will inform my therapist if anything changes before my session

I accept terms & conditions

Signature

Thanks for submitting!

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McLoughlin Scar Tissue Release Approved Practitioner

A professional member of CThA and CHNC . CTha and CHNC does not endorse or approve any products or services

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The Soothicity name and the Soothicity "Rising Sun Lotus" are Registered Trademarks and may only be used with permission from Protea Therapies Ltd

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