New Client Form

How did you hear about us? *

Service booked with us *

What do you want to gain from your session? *

What do you do for stress reduction? How frequently? (Ex: exercise, walking, meditation, etc.) *

Massage/ALT History *

This is my first time for ALT/Massage. I've had ALT/Massage before.

DAY of APPOINTMENT - ADVISE IF.... *

MEDICAL HISTORY

HISTORICAL CONDITIONS
Check all that apply

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE
IMPORTANT: This Current Conditions and Questionnaire is mandatory before your first ALT treatment. In certain circumstances, ALT therapy is contraindicated.

ALT STEP ONE: Please read the Rightway Health and Wellness article linked here before proceeding with health history and current conditions form below.

Click Here for link
drive.google.com/file/d/1GimZa-O7J7ndwDzwtywB1V99WmwEd9hf/view

I have read and understand the Rightway Health and Wellness Article, Contraindications and other information provided within. *

Yes, I understand, agree and will comply No, I have not read it.

CURRENT CONDITIONS
Check all that apply and provide answers to all questions.

ASSISTED LYMPHATIC THERAPY PREPARATION
For best results from your treatment, follow these steps

ONE DAY BEFORE ALT TREATMENT
It is very important to hydrate, by drinking ½ of your body weight in ounces of water.
Use this formula and example as your guide.

Formula: Your body weight /2 = __ oz of water, then /8 oz. = the approximate glasses of water per day.

Example: You weigh 140 pounds, so you would drink 70 ounces of water or approx. 9 glasses. (140 divided by 2 = 70 oz. of water, then divided by 8 oz. = approximately 9 glasses of water)

DAY OF ALT TREATMENT

Avoid using deodorant
Avoid using body lotion
Wear cotton underwear if possible (to avoid compression of the lymph in your hips)

AFTER ALT TREATMENT

Drink ½ of your body weight in ounces of water for 2-3 days after your treatment (See the above formula)

FOR OPTIMAL RESULTS, CONSIDER ADDING THESE TO YOUR ROUTINE

Walking
Dead Sea Salt foot soaks or baths
Electrolytes or trace minerals
Avoid alcohol for 2-3 days

Health Disclosure and Appointment Cancellation Policy Agreement

A massage therapist must be aware of any existing physical conditions that I have, I have listed all my known medical conditions and physical limitations and will inform the massage therapist in writing of any change in my physical health. I understand that a massage therapist does not diagnose illness, disease, or any other medical, physical, or emotional disorder, nor do they perform any spinal manipulations or claim to cure disease and illness.
I am responsible for consulting a qualified physician for any physical ailment that I have prior to seeking massage or other modality therapy from Ayaa Massage/My Lighted Life.
I have disclosed all necessary health information, understand the preparation and follow up instructions, and agree to Massage, and/or Assisted Lymphatic Therapy (ALT) treatment(s).
If I cancel within 24 hours of my scheduled appointment and, I agree to pay the full dollar amount of my appointment.
I understand I can find HIPAA disclosure information related to my healthcare through this link provided by the U.S. Dept of Health and Human Services: www.hhs.gov/hipaa/for-individuals/index.html
I agree that by typing or signing my name on this form, and/or submitting this form that it will represent my willful and legal signature for this document, and booked therapy.

New Client Form

NEW CLIENT FORM & QUESTIONNAIRE
IMPORTANT: This Health History, Current Conditions and Questionnaire is mandatory before your first treatment. In certain circumstances, Massage or ALT therapy is contraindicated.

SERVICES INFORMATION

MEDICAL HISTORY

HISTORICAL CONDITIONS
Check all that apply

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE
IMPORTANT: This Current Conditions and Questionnaire is mandatory before your first ALT treatment. In certain circumstances, ALT therapy is contraindicated.

CURRENT CONDITIONS
Check all that apply and provide answers to all questions.

ASSISTED LYMPHATIC THERAPY PREPARATION
For best results from your treatment, follow these steps

Health Disclosure and Appointment Cancellation Policy Agreement

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New Client Form

NEW CLIENT FORM & QUESTIONNAIRE​IMPORTANT: This Health History, Current Conditions and Questionnaire is mandatory before your first treatment. ​In certain circumstances, Massage or ALT therapy is contraindicated.

SERVICES INFORMATION

MEDICAL HISTORY

HISTORICAL CONDITIONSCheck all that apply

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE​IMPORTANT: This Current Conditions and Questionnaire is mandatory before your first ALT treatment. ​In certain circumstances, ALT therapy is contraindicated.

CURRENT CONDITIONSCheck all that apply and provide answers to all questions.

ASSISTED LYMPHATIC THERAPY PREPARATION For best results from your treatment, follow these steps

Health Disclosure and Appointment Cancellation Policy Agreement

Watch, Like , Subscribe and Connect on our Socials!

NEW CLIENT FORM & QUESTIONNAIRE
IMPORTANT: This Health History, Current Conditions and Questionnaire is mandatory before your first treatment. In certain circumstances, Massage or ALT therapy is contraindicated.

HISTORICAL CONDITIONS
Check all that apply

ASSISTED LYMPHATIC THERAPY (ALT) QUESTIONNAIRE
IMPORTANT: This Current Conditions and Questionnaire is mandatory before your first ALT treatment. In certain circumstances, ALT therapy is contraindicated.

CURRENT CONDITIONS
Check all that apply and provide answers to all questions.

ASSISTED LYMPHATIC THERAPY PREPARATION
For best results from your treatment, follow these steps