Relationship to client:________________ Referred
by:___________________________
Personal Health History: Please write down past or current symptoms
for each category Abdominal pain
Allergies
Arthritis
Aneurysm
Lymphatic Drainage Intake Form
Are you currently undergoing cancer treatments?
__________________
If yes, do you have written permission from your treatment team, to
receive Manual Lymphatic Drainage,
at this
time?____________________________________________________________________________
For Prenatal Clients:
Are you still experiencing morning
sickness?___________________________________
Have you been told you are a high risk pregnancy?____________ If
Yes, Do you have written permission
from your Obstetrician to receive Manual lymph drainage at this
time?____________
For Medical Referral Clients:
Manual lymphatic drainage should not be performed under certain
medical conditions, I
affirm that I have stated all my known medical conditions and
answered all questions
honestly and to the best of my knowledge. I agree to keep the
practitioner updated as to
any changes in my medical profile and understand that there shall
be no liability on the
practitioners part should I fail to do so.
Client
Signature____________________________________Date:__________________
Practitioner
Signature:_______________________________Date:__________________
Consent to treatment of Minor :
By my signature below, I hereby authorize the certified manual
lymphatic drainage therapist, to administer
manual lymphatic drainage to my child or dependent as they deem
necessary.
Signature of Parent/Guardian:__________________________
Date:________________
What is the reason you are seeking lymphatic drainage today?
____________________________
*Please note: Manual Lymphatic Drainage (MLD) aka Lymphatic
Massage, is a very powerful modality, and certain medical
conditions are contraindicated and determine if and when you can
receive a session. After consultation and review of the information
you have provided on this form, it will be determined if MLD should
be administered to you today. Some conditions will require a note
from your doctor, or consultation between your referring provider
and myself, before proceeding. Please understand this is for your
safety and well-being.
I understand that manual lymphatic drainage should not be
considered a substitute for medical examination, diagnosis, or
treatment, and I should see a physician, or other qualified medical
specialist for any mental or physical ailment of which I am aware.
I understand that I will not be diagnosed, prescribed, or treated
for any physical or mental illness, and that nothing said in the
course of the sessions should be construed as such.
Please provide any other information, medical or otherwise, not
specified in this intake form that you feel is important for the
practitioner to know:_________________________
Do you give the practitioner permission to consult with your
referring provider your protected health information for the
purpose of this visit? No____Yes- (Please sign HIPAA Form.)
HIPAA NOTICE OF PRIVACY PRACTICES
We are required by law to: * Make sure that health information that
identifies you is kept private * Give you this Notice of our legal
duties and privacy practices with respect to health information
about you * Follow the terms of the Notice that is currently in
effect
How we may use and disclose health information about you:
Changes to this Notice: We reserve the right to change this Notice.
We will post a copy of the current notice in our facility with the
current effective date.
(Effective August 1, 2019)
For complete, detailed information regarding privacy laws, visit
www.hhs.gov/hipaa
We understand that health information about you is very personal
and we are mandated by the Health Insurance Portability and
Accountability Act (HIPAA) to protecting your health information.
We create a record of the care and services you receive from us,
and this record helps to provide you with quality care and to
comply with certain legal requirements. This Notice applies to all
of the records of your care generated by us, and informs you about
the ways in which we may use and disclose information about you. We
also describe your rights to the health information we keep about
you, and describe certain obligations we have regarding the use and
disclosure of your health information.
Your Medical Records: The original copy of your HIPAA form is our
property. You may request a copy of your records to be transferred
by completing a medical records release form. As allowed by New
Mexico state law, there will be a fee for providing you with this
service. We require 14 business days from the date of your request
to prepare and send your records unless the records are for urgent
of life threatening health issues.
Complaints: If you believe that your privacy rights have been
violated, you may file a complaint with us. All complaints must be
in writing. Please contact us to file a complaint. For complete,
detailed information regarding privacy laws, visit
www.hhs.gov/hipaa
* For Treatment * Public Health risks * For Payment * Health
oversight activities * For Healthcare operations * Lawsuits and
disputes * For appointment reminders * Law enforcement * As
required by law * To avert a serious threat to health and safety *
Coroners, health examiners and funeral directors * National
Security and Intelligence activities * Protective Services for the
President and others * Security Officials for Inmates
______________________________________________________________________________________
_____________________________________________________________________________
Date _____________________________________
We request that you sign this form acknowledging you have received,
read, and reviewed the HIPAA Notice of Privacy Practices. If the
patient is a minor, the legal guardian is automatically appointed
by law to provide/receive protected information on behalf of the
patient. I will notify Dr. Bornaei and/or her staff of any changes
or updates to this record. This acknowledgement will become part of
your records.
Acknowledgement of Receipt of HIPAA NOTICE OF PRIVACY
PRACTICES:
