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Concierge Lymphatic Massage Therapy Intake Form
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2023-10-23T15:29:48+00:00
CONCIERGE LYMPHATIC MASSAGE THERAPY - INTAKE FORM
Name
Email
Date
Address
City
State
Zip
Procedure
Date of Procedure
Name of Surgeon
Name of Company
Address
Country
Did you receive post op care such as massage, lymph massage, any type of therapy from the facility?
Yes
No
If yes, what did you have done?
How are you feeling as you book your appointment? Please be as descriptive as possible.
Post op care instructions:
Future Surgeon/Doctor appointment dates:
Do you have a fever today?
Yes
No
Do you or did you have a drain(s)?
Yes
No
Do you have an infection?
Yes
No
Are you on antibiotics?
Yes
No
If yes, name of doctor prescribing antibiotics
Name of antibiotic
Date issued
Completion date
Medications
Include any diuretics and pain medications.
Emergency contact/phone number
If you are human, leave this field blank.
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