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Lymphatic Drainage Massage (Body)
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Home
Treatments
Skin Treatment
The Boon Method Signature Facial
Signature Holistic Skin Reset Facial
Nervous System Reset Facial
Advanced Skin Renewal (Microneedling)
Skin Smooth & Glow (Dermaplaning Facial)
Skin Resurfacing Peel (Chemical Peel)
Face Sculpt & Fascia Release
Face Lymphatic Drainage Massage
Signature Face, Neck & Head Healing Therapy
Massage Treatments
Lymphatic Drainage Massage (Body)
Myofascial Release Therapy (Face & Upper Body)
Head Healing & Nourishing Oil Therapy
About Us
Reviews
Blog
Contact us
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Lymphatic Drainage Consultation & Consent Form
Please complete this form before your appointment.
Client Details
Full name
Date of birth
Mobile number
Email address
Address
Emergency contact name
Emergency contact number
GP name and surgery
Medical History (Please tick everything that applies.)
High blood pressure
Low blood pressure
Heart condition or heart failure
Diabetes
Kidney disease
Liver disease
Thyroid condition
Autoimmune or inflammatory condition
Cancer, current or previous
Blood clotting disorder or DVT
Taking blood-thinning medication
Epilepsy
Asthma
Pregnant or breastfeeding
Allergies
Recent illness, infection or fever
None of the above
Please give details of any conditions selected above
Current medication, supplements or injections
Allergies or sensitivities
Previous operations, hospital treatment or relevant medical history
Lymphatic and Health Screening
Lymphatic and Health Screening
Diagnosed lymphoedema
Unexplained swelling
Previous cellulitis
Active infection or fever
Current or suspected DVT/blood clot
Uncontrolled heart condition or heart failure
Severe or uncontrolled kidney disease
Severe or uncontrolled liver disease
Cancer treatment or oncology follow-up
Recent surgery
Varicose veins
Unexplained pain or sudden swelling
Pregnancy
Pacemaker or implanted medical device
None of the above
Where do you experience swelling, heaviness, puffiness or fluid retention?
When did it start, and what makes it better or worse?
Any medical diagnosis, investigations or advice relating to the swelling?
Main goals for treatment
Treatment Preferences
Face and neck
Abdomen
Arms
Legs
Back
Full body
Other
Preferred treatment duration
Areas to avoid or any discomfort with touch or positioning
Lymphatic Drainage Consent
Manual lymphatic drainage is a gentle complementary treatment intended to support lymphatic flow and relaxation. It does not diagnose or treat a medical condition and is not a replacement for medical care.
I confirm that the information provided is accurate and complete.
I agree to inform my therapist of any changes to my health, medication, pregnancy status or medical treatment.
I understand that treatment may be postponed and medical clearance requested if there are safety concerns.
I consent to manual lymphatic drainage treatment.
Digital Signature and Treatment Record
Client full name as digital signature
Date
Therapist assessment and areas treated
Treatment response and notes
Aftercare and follow-up recommendation
Therapist name / signature
Submit Details
