Pre-Operative Online Consultation Form - Boon Holistic Skin & Wellness

Appointment type

Pre-operative MLD Post-operative MLD Follow-up treatment

Main reason for attending / treatment goals

Communication And Accessibility

Do you need any assistance, reasonable adjustments or a chaperone?

Yes No

Please provide details

Medical History

Please give details of anything ticked above, including dates and current status

Current prescribed medication, injections, supplements or blood-thinning medication

Allergies or reactions (including medication, latex, adhesives, dressings, oils or skincare)

Have you ever fainted, become dizzy or reacted unexpectedly during treatment?

Yes No

Type of surgery / procedure

Reason / category

Medical Cosmetic Reconstructive Other

Hospital / clinic nsultan

Surgeon / consultant

Surgeon / clinic contact details (if available)

Areas operated on / planned treatment area

Any surgical complications, readmission or unexpected concerns?

Yes No

Post-operative Recovery - Complete If Applicable

Have you received clearance or instructions from your surgeon / healthcare team?

Yes No

Are any wounds open, leaking, inflamed or not healing as expected?

Yes No

Do you currently have drains, stitches, staples, dressings or surgical glue?

Yes No

Have you been diagnosed with a seroma or had fluid aspirated?

Yes No

Are you wearing a compression garment?

Yes No

Do you have sudden or worsening pain, redness, heat, swelling, breathlessness or calf pain?

Yes No

Please provide details, including drain removal date, garment instructions and any surgeon restrictions

I confirm that the information I have provided is accurate and complete to the best of my knowledge

I understand that Manual Lymphatic Drainage is a gentle complementary treatment and does not replace medical assessment, diagnosis or treatment.

I understand that treatment will be adapted to my procedure, health, stage of healing and the advice of my medical team.

I understand that treatment may be modified, postponed or declined if it is not considered safe or appropriate.

I agree to tell my therapist immediately about pain, dizziness, nausea, breathlessness, discomfort or any change in symptoms during treatment.

I agree to update BOON about changes to my health, medication, pregnancy status, surgery, wounds or medical advice before future appointments.

I understand that individual responses vary and no particular result can be guaranteed.

I consent to receiving pre- and/or post-operative Manual Lymphatic Drainage treatment.

Photograph Consent - Optional

I consent to photographs being taken and stored as part of my confidential treatment record. I consent to anonymised photographs being used for professional education or marketing. I do not consent to photographs being used for marketing.

Privacy And Record Keeping

Your personal and health information will be used for consultation, treatment planning, safety, record keeping and appointment-related communication. Records will be stored securely and handled in accordance with applicable UK data-protection requirements.

I confirm that I have read and understood the privacy information above.

CLIENT DECLARATION AND DIGITAL SIGNATURE

Client full name (typing your name acts as your digital signature)

Parent / guardian name and relationship, if applicable Date

PRE-TREATMENT ASSESSMENT

Medical clearance required?

Yes No

Clearance received?

Yes No

Contraindications / precautions / surgeon restrictions

Visual / palpation assessment, swelling distribution and tissue observations

Agreed treatment plan and areas to avoid

Pain score before / after

Areas treated and lymphatic pathways used

Techniques, pressure and positioning

Client response and any adverse symptoms

AFTERCARE AND FOLLOW-UP

Aftercare given / compression or mobility advice within scope

Follow-up recommendation / referral or escalation

THERAPIST DECLARATION

I confirm that I reviewed the consultation information and carried out treatment within my training and scope of practice.

Pre & Post-Operative Manual Lymphatic Drainage