BODY TREATMENT

Lymphatic Drainage or Anti-Cellulite Massage

Quick Intake & Consent Form

All information is confidential.

1. CLIENT DETAILS

Full Name

Phone

Email

Date of Birth
Format: DD/MM/YY (e.g. 25/12/95)

2. TREATMENT SELECTION (SELECT ONE)

Lymphatic Drainage Massage – gentle, light-pressure treatmentAnti-Cellulite Massage – deep, intense pressure treatment

Lymphatic Drainage Massage – Benefits:

• Reduces swelling and fluid retention

• Supports lymphatic system function

• Improves circulation

• Helps reduce bloating and supports bowel function

• Promotes detox and relaxation

Anti-Cellulite Massage – Purpose:

• Targets cellulite reduction

• Improves skin texture and firmness

• Focuses on legs, thighs, and hips

• Stimulates blood circulation and fat metabolism

3. PRESSURE AWARENESS & CONFIRMATION

I understand that Lymphatic Drainage Massage uses very light, gentle pressureI understand that Anti-Cellulite Massage uses strong, deep, and intense pressure

4. BODY AREAS TO BE TREATED

Legs / ThighsHips / GlutesAbdomenArmsFull Body

TREATMENT GOALS – LYMPHATIC DRAINAGE

(Complete only if Lymphatic Drainage Massage is selected)

Reduce swelling / edemaImprove lymphatic circulationPost-operative recoveryDetox supportRelaxation

TREATMENT GOALS – ANTI-CELLULITE MASSAGE

(Complete only if Anti-Cellulite Massage is selected)

Reduce visible celluliteImprove skin firmness & textureLocal fat reductionImprove circulation in legsPost-pregnancy body shaping

Other goal

Important Information

Post-pregnancy body shaping treatments may begin from 6 weeks after a natural birth or 8–12 weeks after a caesarean section, with medical clearance if required. Treatments are adapted to support recovery, improve circulation, and enhance skin firmness. Please inform your therapist if you are breastfeeding or have had any postnatal complications.

How many sessions are you planning?
Single sessionPackage

If package, please specify

5. HEALTH CHECK (IMPORTANT)

PregnancyBlood clots / thrombosisHeart conditionKidney conditionActive infection or feverSkin condition or bruising tendencyRecent surgery (last 6 months)Varicose veinsLymphedemaSwelling / fluid retentionChronic inflammationPost-surgical swellingLipedemaFrequent infectionsAutoimmune conditionCancer (current or past)Thyroid disorderNone of the above

If yes, please specify

Please indicate how you were referred to our clinic.

Google SearchSocial MediaReferral from Friend or FamilyOnline ReviewsExisting / Returning ClientWalk-inOther

6. DATA | COMMUNICATION CONSENT (GDPR) | ACKNOWLEDGEMENT

This information is collected for clinical administration and service evaluation purposes only and will be processed in accordance with GDPR and our Privacy Policy.

I confirm that I have read and understood the treatment differences, pressure levels, and goals, and I consent to receive the selected treatment.
I consent to the collection and storage of my personal data for treatment, record-keeping, and billing purposes.

I agree to receive appointment reminders and clinic communications.

I agree to receive promotional offers (optional).

Signature (Type Full Name)

Date