Lymphatic Request Form

Dayton Therapeutic Massage & Wellness

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Lymphatic Request Form
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Services & Rates
Lymphatic Request Form
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Contact

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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.

*At this time our our office will not be able to work on any client with a Lymphedema diagnosis. A specialized "Lymphedema Certified Practitioner" or Vascular Surgeon will help refer you to the appropriate practitioner for your complex diagnosis.

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

* Indicates required field

Your Name *

First

Last

Your email *

The best phone number or email to contact you

Phone Number *

Why are you seeking Lymphatic Therapy? Please also include the Physician's name who has cleared you to receive Lymphatic Therapy. (If this is for post-op procedures, please provide the dates and type of procedure and any complications, issues or concerns) *

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

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