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Page 1: Lymphatic Drainage Intake Form - Cimpress

Name: __________________________________________ Today’s Date:_________

Address:________________________________________________________________

Phone:___________________________Email:__________________________________

Emergency Contact: Name_____________________ Phone:__________________

Relationship to client:________________ Referred by:___________________________

Personal Health History: Please write down past or current symptoms for each category Abdominal pain

Allergies

Arthritis

Aneurysm

Autoimmune disorder

Bowel problems

Blood clots

Broken bones

Bruise Easily

Cancer:

Cardiovascular problem:

Chronic Bronchitis

Chronic Constipation

Chronic Ear infections

Congestive Heart Failure

Clotting

Deep vein thrombosis

Depression/Anxiety

Diabetes

Enlarged lymph nodes

Fatigue

fever

Fibrocystic Breast

Gastrointestinal Issues

Heart Attack

Head Injury/Concussion

Hematologic/Lymphatic issues

High blood pressure

HIV/AIDS

Infection

Kidney infections/stones

Liver Disease

Low Blood pressure

Lung Disease

Migraine Headaches

Major organ failure

Major scars

Musculoskeletal

Nausea

Neurologic Issues

Neuropathy

Pneumonia

Pregnancy

Sinus congestion or problems

Skin issues

Stroke

Surgery

Swelling

Tinnitus

Thyroid Disorder/disease

Transient Ischemic Attack

Weight gain

Other:

Are you a new patient? Yes No

Lymphatic Drainage Intake Form

Page 2: Lymphatic Drainage Intake Form - Cimpress

For Cancer Clients:

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?____________________________________________________________________________

If no, what was the date of your last treatment?________________________________________________

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:

Medications currently taking:

_____________________________________________________________________

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 powerfulmodality, 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 thisform, 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.)

Page 3: Lymphatic Drainage Intake Form - Cimpress

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 legalrequirements. 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

Your rights regarding Health Information about you: * Right to inspect and copy * Right to Amend * Right to Accounting of Disclosures * Right to Request Restrictions * Right to Request Confidential Communication

Page 4: Lymphatic Drainage Intake Form - Cimpress

Permission to Share your Health Information: We are required to follow certain federal guidelines and laws regarding the confidentiality of your personal health information. One of these prevents us from discussing anything in your medical file with anyone other than yourself or other medical personnel involved in your care. If you would like us to discuss lab results or other personal information with your significant other, family members, or any other individuals, please fill in their name and relationship to you in the section listed below. ______________________________________________________________________________________

______________________________________________________________________________________

_____________________________________________________________________________

Printed Name of Patient and Signature of Patient

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:


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