Holistic Lymphatic Massage & Wellness in Santa Rosa

Health Intake & Treatment Consent Form

Please allow 10 minutes to complete this paperwork. Make sure to complete it at least 48-hours before your appointment whenever possible so that our staff has ample time to review it. This form includes all of our services and in most cases, the only consent for you'll need to complete. Please let us know if there are changes to your health that would require an updated form.

First Name *

Last Name *

Address

City

State

Date of birth *

Would you like to be added to our VIP list for specials and discounts? (1 special offer message per every 1-3 months on average. We NEVER SPAM you!) Choose all that apply

Phone *

Email *

Emergency Contact Name & Phone Number *

How did you hear about us? *

Today's Date *

What would you like to focus on for your initial visit, and subsequent future visits? *

ACKNOWLEDGEMENTS

Acknowledge below: You will need to check in upon arrival by texting (866) 773-3633. Please do not enter until instructed to do so *

I understand

Acknowledge below: You understand that being 15 minutes late or more will result in forfeiting the scheduled service. *

I understand

Acknowledge below: We do not keep cash on the premises. If paying cash, please bring exact change *

I understand

Acknowledge below: We have a no children and no guest policy. Please do not bring anyone with you to your appointment without prior approval. *

I understand

Acknowledge below: Body Contouring Clients -Before, during and after pictures or videos will be taken to document the treatment. These pictures or videos become the property of SPMWC and may be used for its legitimate business purposes. Every effort will be made to crop or remove identifying markers. *

I understand

I acknowledge that is it my responsibility to inform my treating technician of any changes to my health *

I understand

Initial below that you understand: You are responsible for the full payment of the services rendered including add-ons, upgrades or retail products purchased during your visit *

Clear

Initial Below that you understand: We have a strict 48-hour appointment change policy for cancellations or reschedules. Failure to provide 48-hour notice will result in the loss of your deposit, or your card on file being charged 50% of the service total if no deposit was taken. If you have a prepaid service or voucher, it will be forefeitted in full if the 50%late cancellation/change fee is not paid. *

Clear

Initial below that you understand: We have a no refund policy. Due to the nature of the services, all sales on services, packages and products are final. There are no exceptions. *

Clear

Initial below that you understand: We take chargebacks seriously! The Lymphatic Lounge will pursue legal action for chargebacks to recover not only the full amount owed but also legal fees and associated costs. We maintain records of all communications, sales and services and will provide them to the appropriate entities. *

Clear

Have you had any surgeries in the last 6 months? If yes, please explain *

Yes

If yes, please explain any surgeries or proceedures:

(Female Clients) Are you currently pregnant?

Yes

Not Applicable

(Female Clients) Are you currently nursing?

Yes

Not Applicable

Do you have any allergies or sensitivities? (includes nuts, fruits etc) *

Yes

Please explain any allergies including nuts, fruit, flowers etc:

Do you have any blood disorders or are you prone to clotting? *

Yes

Do you have any chronic medical conditions that we should know about? Please describe in detail and explain checked boxes above if applicable. Type "None" if not applicable. *

Are you taking any medications? *

Yes

If yes, please list medication name and use: (Must not be on Antibiotics and/or Steroids in the last 14 days *

Do any of the following apply to the are being treated? *

Sunburn or excessive sun exposure (last 7 days)

Chemical Peel//Microneedling (last 4 weeks)

Botox/Fillers (last 8 weeks)

Laser Hair Removal/Skin resurfacing (last 6 weeks)

Cuts/Burns/Abrasions/Rash/Bruises

Retin A (Tretinoin, Vit A, Renova, Retonic Acid)

None

Are you under the care of a physician for anything that isn't listed above? *

Yes

Please explain why you're under physicians care, or type "N/a" *

Additional conditions/situations that may requiring a waiting period, or avoiding the area for depending on treatment type:

-Skin conditions such as eczema, dermatitis, or rashes. Any kind of rash or skin disfunction must be diagnosed AND something thats non-communicable and something that won't spread to other areas of your body (ie like during a full body massage that is increasing circulation etc). We are still required to avoid the area and wear gloves. You are not a candidate for tratment if rash or skin disfunction is undiagnosed by a medical professional.

-Open Wounds. Open wounds must be healed prior to appointment.

-Bruises. Bruised area will be avoided.

-Illness. To keep our staff and our other clients safe, clients with ANY illness symptoms (cough, sneezing, runny nose, fever, rash, etc) will need to reschedule. There are NO exceptions to this rule. Please do not show up sick- you will be sent home.

-Seasonal Allergies. Unfortunatly allergy symptoms are almost identical to illness symptoms ans there is no way for our staff to know the difference by just looking at a client. If you have controlled allergies, you may still schedule. If your allergies are uncontrolled, ie sneexing/coughing often- you will not be able to schedule while you're having allergy symptoms.

Do you have any medical devices implanted including, but not limited to: Hearing aids, a pacemaker, or hormonal pellets? Please list or type "No" if you have none *

Do you require any accommodations/assistance during your visit? *

Yes, I'm unable to climb stairs easily/safely

Yes, I need help getting onto/Off of the treatment table

Yes, I'm hard of hearing/hearing impaired

No, I need no accommodations/assistance

How many ounces of water do you drink daily? *

By signing below, I affirm that the above information is correct. I understand that it is my responsibility to let the treating technician know if something has changed that would disqualify me from further treatments, or that would require me to wait before continuing, prior to scheduled appointments. *

Clear

By signing below, I agree to the following and consent to proceed with the treatment.

Please carefully read and sign this liability waiver to acknowledge your understanding of the risks involved and to release Sanctuary Pain Management and Wellness Center and its employees and associates from any and all liability for any injury, loss, or damage that may occur as a result of the treatment.

1. Risks and Side Effects: Massage therapy, while generally safe and beneficial, carries certain risks and potential side effects. These may include, but are not limited to:
   a. Soreness or Discomfort: It is common to experience temporary soreness or discomfort during or after a massage session, particularly if deep tissue or intense pressure techniques are used.
   b. Allergic Reactions: Some individuals may experience an allergic reaction to massage oils, lotions, or other products used during the session.
   c. Bruising or Skin Irritation: In rare cases, massage techniques or pressure may cause bruising or skin irritation.
   d. Pre-existing Conditions: If you have any pre-existing medical conditions, such as cardiovascular issues, diabetes, or musculoskeletal injuries, there may be an increased risk of complications or adverse reactions.
   e. Infection: Although rare, while strict hygiene practices are followed, there is a minimal risk of infection associated with any skin-penetrating procedure.
   f. Other Risks: There may be other risks and side effects associated with massage therapy that are not listed here.

2. Risks and Side Effects: Facial treatments, including but not limited to facials, chemical peels, microdermabrasion, and facial massages, carry certain risks and potential side effects. These may include, but are not limited to:
   a. Skin Irritation or Sensitivity: Some individuals may experience temporary redness, itching, or irritation after a facial treatment.
   b. Allergic Reactions: There is a minimal risk of allergic reactions to the products used during the facial treatment, such as cleansers, masks, serums, or creams.
   c. Skin Breakouts: In rare cases, facial treatments may cause temporary breakouts or acne flare-ups due to the skin purging toxins or reacting to the treatment.
   d. Sun Sensitivity: Certain facial treatments, such as chemical peels, may increase skin sensitivity to the sun, making it more prone to sunburn or hyperpigmentation.
   e. Skin Discoloration: There is a slight risk of temporary or permanent skin discoloration, particularly with aggressive or improper use of chemical peels or other treatments.
f. Infection: Although rare, while strict hygiene practices are followed, there is a minimal risk of infection associated with any skin-penetrating procedure.
g. Unsatisfactory Results: While facial treatments aim to improve skin condition and appearance, there is no guarantee of achieving the desired results.
h. Other Risks: There may be other risks and side effects associated with facial treatments that are not listed here.

3. Risks and Side Effects: Body contouring procedures, including but not limited to non-invasive fat reduction including cavitation, LLLT (Low level light therapy aka laser liposuction), fat dissolve wraps and serums, and skin tightening treatments including but not limited to radio frequency, electroporation, Kuma shape, yeso wraps, skin tightening wraps and serums, Muscle building treatments including but not limited to Vibration therapy, EMS or HIEMT, carry certain risks and potential side effects. These may include, but are not limited to:

   a. Redness: Some individuals may experience temporary redness, itching, or irritation after a body contouring treatment.
b. Bruising and Swelling: It is possible to experience bruising and swelling after body contouring procedures, which may take several weeks to subside.
c. Skin Irregularities: There is a possibility of uneven or irregular skin texture, contour, or coloration following the procedure.
d. Numbness or Sensitivity: Temporary numbness or sensitivity in the treated area may occur.
e. Allergic Reactions: Some individuals may experience an allergic reaction to the materials used during the procedure.
f. Unsatisfactory Results: While body contouring procedures aim to improve body shape and appearance, there is no guarantee of achieving the desired results.
g. Muscle Soreness: Soreness or Discomfort: It is common to experience temporary soreness or discomfort during or after a body contouring treatment, primarily but not exclusively with EMS or HIEMT.
h. Infection: Although rare, while strict hygiene practices are followed, there is a minimal risk of infection associated with any skin-penetrating procedure.
I. Other Risks: There may be other risks and side effects associated with body contouring procedures that are not listed here.

4. Risks and Side Effects: Cupping Therapy including but not limited to cupping for pain relief, cupping for swelling or cupping for lymphatic drainage.

a. Bruising or discoloration of the skin: Cupping may cause temporary marks or discoloration on the treated area, which typically fade within a few days to a couple of weeks.
b. Sensitivity or discomfort: Cupping may cause temporary discomfort or sensitivity in the treated area, which should subside shortly after the treatment.
c. Skin irritation or allergic reactions: Although rare, there is a possibility of experiencing skin irritation or allergic reactions to the materials used during the cupping treatment.
d. Infection: While strict hygiene practices are followed, there is a minimal risk of infection associated with any skin-penetrating procedure.
e. Other Risks: There may be other risks and side effects associated with cupping procedures that are not listed here.

5. Risks and Side Effects: TeraHertz/ BioHertz aka Bioresonance Therapy is a safe and gentle treatment but may come with potential detoxification related side effects.

a. Temporary detoxification symptoms including but not limited to: Tiredness, headaches, rash or worsening of existing rash, bruising, sun sensitivity, soreness, redness, blistering, itching, nausea, bloating, numbness, aches, sweating, frequent Urination, fever, feeling hot or cold. Detox symptoms typically fade within a few days and can be lessoned with staying hydrated with water.
b. Sensitivity or discomfort: Terahertz/BioHertz aka Bioresonance may cause temporary discomfort or sensitivity in the treated area, which should subside shortly after the treatment.
c. Other Risks: There may be other risks and side effects associated with Terahertz/BioHertz aka Bioresonance Therapy that are not listed here.

Consent for treatment:
I confirm that I am over the age of 18. By signing below, I affirm that the above information is correct. I understand that it is my responsibility to let the treating technician know if something has changed that would disqualify me from further treatments, or that would require me to wait before continuing, prior to scheduled appointments. I understand that certain treatments are permanent, and that such procedures have possible adverse consequences. I certify that I have read the above paragraphs; fully understand this consent and procedure form and herby consent to the indicated procedure (s). This means that I accept full responsibility for these and/or any other complications which may arise from requested treatments. I agree to before and after treatment photographs, measurements, and weighing, as this will help for evaluation of the treatment results. Information will be acquired for maintaining records or marketing purposes. I understand this consent is valid for each and every treatment I receive at SPMWC until I revoke this consent in writing.

By signing below, I agree to the terms outlined, the possible risks and consent to treatment *

I agree to use electronic records and signatures

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the Lymph Lounge regarding my appointments and occasional marketing communication. Reply STOP to opt out at anytime.

Client Signature *

Clear

I’m excited to welcome you to The Lymphatic Lounge

and I look forward to helping you relax, refresh and reset.

I can’t wait to see you soon!

CMT, MBCS, CLHS

At The Lymphatic Lounge, our therapies are designed to eliminate lymphatic congestion and lower cortisol levels, helping you reduce swelling, calm your nervous system, and finally break free from the exhaustion and discomfort holding you back or making you feel trapped in your body.

Unlock exclusive wellness offers and seasonal specials just for FIRST TIME CLIENTS

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At The Lymphatic Lounge, we believe that wellness should be easily accessible, which is why we offer special discounts to make your journey to better health affordable

May use up to 2 of the above $5-$10 off savings specials per visit. Max discount $20 per visit. Not valid with any other discount or special including new guest specials.