Manual Lymphatic Drainage Therapy Intake
This intake form is for those seeking manual lymphatic drainage therapy that is not related to a diagnosis or history of cancer. If you are seeking general therapeutic massage or lymphatic drainage therapy related to any form of cancer diagnosis or treatment please complete the appropriate intake form at
Email address *
Your Information
Please share your basic contact information and contact preferences so that I know the best way to stay in touch.
Name *
Your answer
Date of Birth *
Address *
Your answer
Telephone Number *
Your answer
Preferred Contact Method *
Would you like to receive a weekly email offering open sessions when available? *
Would you like to receive an occasional newsletter with information and resources? *
How did you hear about me?
If you were referred to me are you willing to let me thank the person? If so please share their name.
Your answer
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