Lavelle Health — Lymphatic Drainage intake & consent

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About you

Please answer as accurately as you can. Some questions are included to help Rae decide whether treatment should be modified, delayed, or cleared by a medical provider.

Full name *

Preferred name

Optional — what you’d like Rae to call you.

Are you 18 or older? *

YesNo

Parent / legal guardian name *

Guardian’s relationship to the client *

Email *

Your copy of this form will be sent here.

Phone *

Date of birth

Optional — helps Rae keep accurate records.

Home address

Emergency contact — name

Emergency contact — phone

How did you hear about Rae?

Your visit

What brings you in? *

Choose everything that applies.

Recovery after surgerySwelling or fluid retentionDiagnosed lymphedemaImmune supportRelaxation & wellbeingSomething else

Tell us a little more

Anything else Rae should know about what you’re hoping to get out of your sessions?

Have you received manual lymphatic drainage before? *

YesNo

Is there anything Rae should know to make your appointment safer or more comfortable?

Health screening

Lymphatic drainage is very gentle, but a few conditions need extra care — or a doctor’s okay — first. Please answer honestly: a “Yes” doesn’t necessarily mean you can’t receive treatment, it just tells Rae what to take into account.

Do you currently have a fever, an infection, or feel generally unwell? *

YesNo

Please give a few details

Do you have a heart condition? *

For example congestive heart failure, an arrhythmia, or a recent cardiac event.

YesNo

Please give a few details

Any history of blood clots, DVT, or a clotting disorder? *

YesNo

Please give a few details

Any kidney problems? *

YesNo

Please give a few details

Any liver disease? *

YesNo

Please give a few details

Are you currently being treated for cancer, or do you have a history of cancer? *

YesNo

Please give a few details

Have you ever received chemotherapy or radiation therapy? *

YesNo

What for, and roughly when?

Are you currently pregnant? *

YesNo

How far along are you?

Do you have low blood pressure? *

YesNo

Please give a few details

Do you have asthma or another respiratory condition? *

YesNo

Please give a few details

Do you have a thyroid condition? *

YesNo

Please give a few details

Do you have diabetes? *

YesNo

Please give a few details

Any skin conditions, rashes, or open wounds at the moment? *

YesNo

Please give a few details

Have you had surgery in the last 3 months? *

YesNo

What surgery or procedure did you have? *

Approximate date of the surgery

Surgeon or clinic (optional)

Have you been cleared by your healthcare provider to receive manual lymphatic drainage? *

YesNo

Optional — anything that would help Rae understand your situation.

Thanks for noting this. Rae may need to review this before your appointment and may recommend medical clearance before treatment.

Do you currently have surgical drains, open incisions, wound separation, active bleeding, or signs of infection? *

YesNo

Please give a few details

Thanks for noting this. Rae may need to review this before your appointment and may recommend medical clearance before treatment.

Are you currently taking antibiotics? *

YesNo

What for, if you’d like to share?

Have you had any other surgeries in the past? *

YesNo

Which surgeries, and roughly when?

Have you ever had cosmetic or plastic surgery, such as liposuction, a tummy tuck, breast surgery, a BBL, or body contouring? *

YesNo

Please briefly describe — approximate dates are fine; if you’re not sure, write what you remember.

Have you ever had lymph nodes removed? *

YesNo

Please give a few details

Have you had any new or unexplained swelling that hasn’t been assessed by a healthcare provider? *

YesNo

Please briefly explain — if you’re not sure, write “not sure” and Rae can review it with you before your appointment.

Right now, are you experiencing chest pain, shortness of breath, sudden calf pain or swelling, a fever, or otherwise feeling acutely unwell? *

YesNo

Please give a few details

Thanks for noting this. Rae may need to review this before your appointment and may recommend medical clearance before treatment.

Any other medical conditions, or recent changes in your health? *

YesNo

Please give a few details

Current medications (if any)

Allergies (if any)

Consent

Manual lymphatic drainage (MLD) is a light, rhythmic massage technique that encourages the natural flow of lymph fluid. Your practitioner is Raegan Brumer, LPN, Certified Lymphedema Therapist and post-operative recovery specialist, trained in the Vodder, Chikly, and Godoy methods — “Rae” throughout this form. Sessions are gentle and non-invasive, and take place at Rae’s home studio. Please review each item carefully. These acknowledgements help confirm that you understand the nature and limits of the service before your appointment.

Your agreement is with Raegan Brumer

These services are provided by Raegan Brumer, operating as Lavelle Health. Throughout this form and the payment terms, “Lavelle Health” means Raegan Brumer.

I am the parent or legal guardian of this client, and I consent to this assessment and treatment on their behalf. I am signing on their behalf below. *

I understand that manual lymphatic drainage and related wellness services are not a substitute for medical diagnosis, medical treatment, emergency care, or advice from a physician or regulated healthcare provider. *

I confirm that the information I have provided is accurate and complete to the best of my knowledge. *

I agree to inform Rae of any significant changes to my health, medications, surgery status, pregnancy status, or medical condition before future appointments. *

I understand that Rae may refuse, modify, postpone, or discontinue treatment if she believes treatment may be unsafe, inappropriate, outside her scope, or if medical clearance may be required. *

I understand that certain medical conditions may require physician clearance before treatment can proceed. *

I understand that results are not guaranteed. *

I know I can ask to adjust, pause, or stop my session at any time, for any reason. *

I understand that treatment may include the gluteal area or other sensitive areas where clinically appropriate, such as during post-operative or body-contouring recovery. I will remain appropriately draped, my consent will be confirmed before any such work begins, and I may decline or stop at any time. *

I consent to receiving manual lymphatic drainage from Raegan Brumer, LPN, Certified Lymphedema Therapist (“Rae”). *

I understand that payment is due upon receipt, and I have read and agree to the payment terms. *

Read the full payment terms →

I consent to Lavelle Health collecting, using, storing, and retaining my personal and health information for intake, treatment planning, scheduling, communication, invoicing, recordkeeping, and related client-service purposes. *

Your information is used to provide services and maintain client records — including emailing your completed form to you and to Rae. It is not shared except where required by law, required for safety, or authorized by you.

May Rae also keep an electronic copy of this form on file? *

Printed copies are kept with her client records either way.

Yes — keep my record stored electronically.No — keep printed copies only. The online record is removed automatically after 30 days (long enough to print it).

Acknowledgement & release

I understand that manual lymphatic drainage is a wellness service. I acknowledge that treatment decisions are based on the information I provide. I understand that withholding medical information, providing inaccurate information, failing to follow medical advice, or failing to update Rae about changes to my health may increase the risk of an adverse outcome. I release Lavelle Health and its practitioners from liability arising from undisclosed medical conditions, inaccurate or incomplete information, or my failure to follow medical advice or recommendations.

Signature

Typing your name below signs this form electronically: it confirms you filled it in yourself and agree to the statements above. If the client is under 18, a parent or guardian must complete and sign it.

Type your full name to sign *

Today’s date, recorded with your submission: August 9, 2026

Your intake is sent to Raegan Brumer, operating as Lavelle Health, and used for client records, appointment administration, care-related communication, and payment/insurance documentation where applicable. Information is not sold or used for marketing. It may be shared only with service providers or others where needed, authorized, or required by law.

This form is not monitored for emergencies. If you are experiencing chest pain, shortness of breath, sudden severe swelling, signs of infection, or symptoms that feel urgent, please seek medical care promptly.

Raegan Brumer, operating as Lavelle Health.