Lymphatic Request Form

Dayton Therapeutic Massage & Wellness

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Home
Services & Rates
Lymphatic Request Form
Helpful Links
Contact
Gift Certificates

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Lymphatic Request for New Clients

This form is required before your first Lymphatic appointment can be made.
Once submitted, our office will contact you to complete the booking process.

Please answer as specific as you can, generalized answers or an incomplete form will not be accepted, as this will help determine your eligibility to receive Lymphatic work at our facility.

* Indicates required field

Your Name *

First

Last

Your email *

The best phone number or email to contact you

Why are you seeking Lymphatic Therapy? (If this is for post-op procedures, please provide the type of procedure, date of surgery and any complications, issues or concerns) *

Provide type of symptom, dates of surgery/procedure, and any complications or concerns

Physician's Name and Contact Information whom has cleared you to receive Lymphatic Therapy *

If this is for post surgery or for certain lymphatic conditions, a client must be cleared by a physician before a Lymphatic appointment can be booked.

Check all that apply: *

Swelling Minor Swelling that comes and goes periodically Persistent swelling with heat and redness Inability to walk or move without assistance Inability to sit or lay down Cancer, Surgery or Radiation of Lymph Nodes Hypo/Hyperthyroidism Cardiac Conditions Areas that are leaking or weeping fluid Areas of acute soreness Sinus pain or pressure Post-surgery Upcoming surgery Diagnosis of Lipedema Diagnosis of Lymphedema None of these

Conditions either past or present

Submit