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Surgical Intake
Please fill out intake form to the best of your ability. Thank you for trusting Cypris Bodywork & Wellness with you care! We look forward to treating you!
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Name
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Your answer
Email
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Your answer
What type of procedure did you have? Please provide as much detail as possible ie.: Tummy Tuck with Abdominal Muscle Repair, Smart Liposuction on abdomen, flanks, and thighs
Your answer
When was your procedure?
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Is this your first surgical procedure? If not, please list type of procedures and dates.
Your answer
Who was your surgeon and where is the office located?
Your answer
What, if any, compression garments were you prescribed and how long are you recommended to wear them?
Your answer
Were you given a board or foam inserts? If so, please describe.
Your answer
Did you have any complications with your procedure? If so, please describe.
Your answer
Do you currently have any drains?
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Yes
No
Do you currently have any open wounds? If so, please describe location and size.
Your answer
Have you had any lymph nodes removed?
No
Yes
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What is the recovery time your surgeon gave you?
Your answer
I acknowledge and will adhere to the 48 hour cancelation policy of Cypris Bodywork & Wellness. Any cancellations made less than 48 hours before agreed upon appointment time will be charge the full visit fee of $120.
Yes
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I acknowledge that my appointment starts at the time it is scheduled, and ends promptly at the agreed upon appointment duration. No extra time is given for changing clothes, scheduling or payment.
Yes
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By entering my name in the space below I acknowledge It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. Please type name and date signed below.
Your answer
I will participate fully as a member of my healthcare team. I will make sound choices regarding my sessions’ plan based upon the information provided by my massage therapist. I agree to participate in my own self-care programs and adhere to the plan we select. I agree to communicate with my practitioner any time I feel my well-being is being compromised.
Yes
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I understand that as part of treatment, the therapist may have contact with sensitive areas including the collar bone, front of the neck, arm pits, abdomen, sacrum, groin and inner thigh. I agree to clearly communicate comfort level at all times.
Yes
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Out of an abundance of care and caution, Cypris Bodywork & Wellness requires both therapist and patient to wear a mask at all times, regardless of vaccination status. This is a policy based on the population we specialize in serving, including the immunocompromised and cancer patients. I agree to comply with this mask policy.
Yes
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Please read the article What Is and Isn't Lymphatic Drainage
https://cyprisbodyworkandwellness.com/services
I understand that Lymphatic Drainage is a gentle, non-invasive treatment.
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