Decongestive Lymphatic Drainage Form

Our Energetic Lymphatic Drainage is a patented Swiss technique that addresses the chakras, the meridians and the movement and decongestion of the delicate lymph system.  This gentle, effective therapy for the immune system, the connective tissue and body fluid movement is one of our most essential to health and body balance.

Prior to your first Lymphatic Drainage appointment, please fill out the following form for us.  Please make sure you complete the form and click submit before leaving this page, otherwise your information will not be saved and submitted.

Name *
Please give us a phone number where you can be easily reached: *
Please give us a phone number where you can be easily reached:
Your Date of Birth *
Your Date of Birth
Have you had Lymphatic Drainage before?
Vitamins, minerals, supplements, herbs, OTC remedies, etc.
Breast Health: Please check off all that apply:
General Health: Please check off all that apply
Allergies & Sensitivities
Skin Health: Please check off all that currently apply

I understand that the Lymphatic Drainage therapy that I receive is provided for the basic purpose of decongesting and improving the flow of my lymphatic system.  If I experience any sensitive areas or discomfort during this session, I will immediately inform my therapist so that it may be noted for future treatment planning and so the session may be adjusted to my level of comfort.

I further understand that this treatment is not intended as a substitute for medical examination, diagnosis, or treatment.  I understand that nothing said in the course of the session given should be construed as such.  Because lymph 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. I agree to keep my therapist 
updated as to any changes in my medical profile and understand that there shall be no liability on the therapist's part in administering this treatment.  

You can read more about lymph drainage indications and contraindications by clicking here.

By clicking Submit, I am agreeing to these conditions of my treatment.