763-476-0202 info@tolmassage.com
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Manual Lymphatic Drainage Client Health Form 
Manual Lymphatic Drainage (MLD) is a VERY gentle, slow, repetitive and rhythmic technique that mimics the action of your body’s lymph system and helps to reduce swelling and pain. The Lymphatic System is a key part of your cardiovascular system; therefore, if you have certain heart conditions, it is not advisable to receive MLD treatment. It is critical that the heart and kidneys are functioning well enough to process the lymphatic return that is stimulated by this specialized  technique. If your Lymphatic system itself (i.e. lymph node removal) is itself compromised, certain precautions need to be taken in the MLD treatment.  If you are being treated post surgery, all tubes need to be removed and no fluid will be drained from incision areas during your treatment.

Sign in to Google to save your progress. Learn more
* Indicates required question
Email *
Your email
Client full name *
Your answer
Client phone number *
Your answer
Why are you seeking Manual Lymphatic Drainage? (Condition – please be specific) *
Your answer
Is your visit due to a surgery? *
If yes, What type of surgery 
Your answer
What was the date of the surgery?
Has your condition been diagnosed by a health care professional? (Did they recommend you receive MLD?) *
If yes, please provide the name and phone number of the referring health practitioner.
Your answer
Do you have or have you had any of the following?                                                                                                               *
If YES, please explain.
Your answer
What medications are you currently taking and for what condition are they prescribed? *
Your answer
What to Expect at Your Appointment                                                                                                                          
MLD is a light, skin stretching technique; it requires skin-on-skin contact to be performed effectively. Clients are asked to be completely undressed beneath the sheet and blanket. You will always be professionally draped to maintain your privacy, comfort and warmth. If you feel the need to leave your underwear on, of course, your decision will be respected. Your feeling of safety and comfort is first and foremost. In that case, please be sure that you are wearing briefs, rather than boxers or “boy shorts.”

The Lymphatic System has a specific direction of flow and pathway through the body. Clearing the areas “in front” of the focus area is a key part of the treatment. You can think of it like clearing the leaves and debris from gutters. You cannot ask the gutter to receive more debris, if it is already full. It’s the same with your Lymphatic System. MLD is facilitating greater movement of the lymph fluid and therefore we need to prime and clear the lymph nodes in front of the problem area as well.

Please confirm that you have read the above explanation. *
I understand that a credit card will need to be put on file to hold my appointment. I give Tree of Life authorization to charge my credit card on file for cancellations made within  24 hours of my appointment  and / or no shows.  *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy