Pink&Fancy
Client Intake/Progress Notes
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Email *
First Name *
Last Name *
Address: (Please include street, city, state, zip-code) *
Phone Number *
FDate Of Birth *
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DD
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YYYY
Covid-19 Vaccination Standing *
Required
Please indicate date of which you have received your vaccination
MM
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DD
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YYYY
If not vaccinated please indicate last negative COVID-19 testing date.
MM
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DD
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YYYY
Reason for visit: *
Any Medical Conditions? *
Required
Any Allergies *
Required
Current medications/OTC/Herbal/Supplements: *
Type of Surgery: *
Required
Mastectomy
Affected Side
Lymph Nodes Removed *
Required
Any Drains *
Required
History of Chemo/Radiation *
Required
History of Lymphedema *
Required
*If yes to previous question, were you treated?
Any lymphatic massage/treatment before?
*If yes to previous question, how often?
*If yes to previous question, Date of 1st massage/treatment:
MM
/
DD
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YYYY
*If yes to previous question, Date of LAST massage/treatment:
MM
/
DD
/
YYYY
*If yes to previous question, what part of body?
Please indicate current pain level (1-10) *
Post-op Garment(s) *
Required
Additional Information (For Consultant) *
For Record Keeping Only (Please Provide Full Name)
Date Signed
MM
/
DD
/
YYYY
For Record Keeping and media Release (Please Provide Full Name)
Date Signed
MM
/
DD
/
YYYY
Agreement Terms and Conditions
I, _______, have agreed to the conditions requested by this establishment prior to receiving any service(s).
- Walk ins are NOT allowed: clients, guests, or visitors
- We reserve the right to decline your request for an appointment due to noncompliance to sign the waiver
- We require that you leave your credit card number upon booking an appointment to serve as a deposit equivalent of a service fee to be garnered upon failure to provide a 24 hour notice as noted on this agreement
- To cancel/reschedule my appointment 24 hours ahead of time if I have been exposed to anyone who had been tested positive for the Coronavirus in the past 14 days.
   - A deposit will be required equivalent of a service fee to be garnered for failure to provide a 24 hour notice as noted on this agreement.
   - Cancellations or no shows without the 24 hour notice or less than 24 hour will be billed as service rendered.
- To pay for any or all charges that will be levied on me for failing to comply with the required 24 hour cancellation/rescheduling or no calls/no show on the designated day & time of appointment.
- To waive and not pursue any claims against Pink&Fancy should I experience any Coronavirus symptoms or test positive for the virus after receiving service(s) from my provider.
- Upon arrival at Pink&Fancy:
   1. wear a face mask prior to entering
   2. Wash/Sanitize my hands according to protocol set by the CDC
   3. Consent to have my temperature taken and to cancel/reschedule my appointment if my temperature reads over 99 degrees Fahrenheit.
   4. Allow 14 days to pass before rescheduling of cancelled appointment.

By providing my name below, I am signing for this document. I have read and accepted the terms and conditions and will be held responsible for the information provided. *
A copy of your responses will be emailed to the address you provided.
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