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Uplifting Holistic Facial
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Maternity Reflexology

Indian Head Massage

Uplifting Holistic Facial

Manual Lymphatic Drainage for Lymphoedema

Manual Lymphatic Drainage for Wellbeing

MLD Consent Form

Client Information Form

Facial Information Form

MLD Consent Form

Maternity Reflexology

Indian Head Massage

Uplifting Holistic Facial

Manual Lymphatic Drainage for Lymphoedema

Manual Lymphatic Drainage for Wellbeing

MLD Consent Form

Client Information Form

Facial Information Form

MLD Consent Form

MLD Consultation and Treatment Consent

Manual lymphatic drainage for lymphoedema.

Before I see you on the day, please take the time to complete the following form.
If you have any questions about this process I would be happy to hear from you.

Lymphoedema manual lymphatic drainage Jeanettes reflexology room — MLD for Lymphoedema Godalming, within easy reach of Elstead, Milford, Witley & Bramley

First & surname? *

Date of Birth? *

DD/MM/YYYY

Telephone number? *

Email? *

Email

Confirm Email

Have you been medically diagnosed with lymphoedema? *

CONTRAINDICATIONS: I understand that complete contraindications to the treatment are: *

Any metastatic or systemic malignant condition
Untreated acute heart problems and renal failure
History of thrombosis (DVT) or tuberculosis
While undergoing active cancer treatment, such as chemotherapy or radiotherapy
During an acute infection (such as cellulitis)
During pregnancy
None of the above

If none, please tick none
If you have any of the contraindications listed above, regret MLD cannot be performed.

Precautions are required if Manual Lymphatic Drainage is used in the following conditions which should be disclosed to me and discussed in advance of treatment: *

Oedema following carcinoma treatment
Thyroid dysfunction
Chronic inflammation
Bronchial asthma
Hypotension
Oedema caused by cardiac decompensation
Diabetes
None of the above

If none please tick none

Single Line Text

RISKS AND SIDE EFFECTS:
MLD is regarded as a very low risk treatment and side effects are minimal. Very few people have negative reactions to lymphatic drainage massage.
Short term reported side effects include: Headaches, nausea and fatigue. Long term, more serious side effects are rarely reported but can included: Increase in swelling (due to underlying/undiagnosed cause).
DISCLAIMER
I have read and understand this consent form.
1. I do not currently have any medical condition listed above which will affect treatment.
2. I accept and consent for MLD and other lymphoedema treatments to be used in this way.
3. I understand and accept these risks.
4. All my questions have been satisfactorily answered.
5. I have been given all the information I asked for about the procedure(s), risks, and other options.

I consent to the consultation terms? *

SIGNATURE *

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JEANETTE HAYTON M.A.R., LTA Cert.

Lymphedema_Training_Academy_certificiate_Jeanettes_Reflexology_Room

eco_friendly_therapist

Mian_Dui_Facial_Massage_Certificate

Maternity reflexology certificate

Pass certificate for VTCT Indian Head Massage

Facebook-f Twitter Instagram Youtube Pinterest

JEANETTE HAYTON M.A.R., LTA Cert.

Lymphedema_Training_Academy_certificiate_Jeanettes_Reflexology_Room

Pass certificate for VTCT Indian Head Massage

eco_friendly_therapist

Mian_Dui_Facial_Massage_Certificate

Maternity reflexology certificate