MLD for Wellbeing Information Form Please enable JavaScript in your browser to complete this form.First & surname? *Date of Birth? *DD/MM/YYYYTelephone number? *Email? *EmailConfirm EmailWhy are you seeking manual lymphatic drainage treatment? *Are you pregnant? *--- Select Choice ---NoYesCONTRAINDICATIONS: I understand that complete contraindications to the treatment are: *Acute inflammation &/or infections or feverActive cancer or awaiting test resultsOrgan transplantCirculatory problemsHistory of thrombosis (DVT) or tuberculosisHeart conditions including angina coronary thrombosisKidney conditionsNone of the aboveIf none, please tick noneIf you have any of the contraindications listed above, I will be in touch for more information. 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 treatmentThyroid dysfunctionChronic inflammationBronchial asthmaHypotensionOedema caused by cardiac decompensationDiabetesNone of the aboveIf none please tick none Single Line TextRISKS 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 declare the information in this form to be true, and accept that it is my responsibility to keep my practitioner updated regarding any changes to my health or medication. I am happy to receive holistic facial. * *Submit
