Name *

First Name

Last Name

Date of Birth: *

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DD

YYYY

Phone: *

Country

(###)

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Home Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address- Where you want the massage to take place (mobile / chair event): *

E.g. if you are visiting from out of town this would not be your home address. *If you are coming for an in-studio session please just put the office address: 2186 South Holly, Suite 206 Denver, Colorado 80222

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please Select Your Pronouns: *

she / her

he / him

they / them

Emergency Contact Phone Number: *

Country

(###)

###

####

Date of Initial Visit: *

MM

DD

YYYY

Are you currently pregnant? *

Yes

No

Have you received lymphatic drainage before? *

Yes

No

The Following Conditons Are Contraindicated for Manual Lymphatic Drainage *

You cannot have a session if present - check all that apply / NONE.

Untreated Congestive Heart Failure

Acute Cellulitis

Acute Untreated DVT

Fever

NONE

*Please Review: *

It is my choice to receive massage therapy, bodywork (which may include the use of cupping therapy or Guasha applied to the face or body), and/or lymphatic drainage. I am aware of the benefits and risks of massage therapy, bodywork, and/or lymphatic drainage, and I give my consent for each session I choose to book. I understand that there is no implied or stated guarantee of the success or effectiveness of individual techniques or series of appointments. I acknowledge that each session is not a substitute for medical care, medical examination, or diagnosis. I agree to consult with my doctor prior to receiving massage therapy, bodywork, and/or lymphatic drainage if I have had any surgeries, procedures, medical conditions, or any contraindications whatsoever. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I understand that my personal health information will be collected, and all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. I understand and agree that I am responsible for covering the payment of each session (attended or missed) and no insurance or reimbursements may cover the costs of any session.

I have read through and understand all the policies The Mindful Bodyworker has implemented. I agree with all of them, including the cancellation policy. I release the licensed massage therapist and The Mindful Bodyworker of any responsibility for receiving massage therapy, bodywork (which may include the use of cupping therapy or Guasha applied to the face or body), and/or lymphatic drainage. 

Today's Date: *

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