Cedar Hills Lymphatic and Massage Therapy Clinic New Patient Inquiry Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please note that the information on this form is treated as highly confidential.

Email *

Name *

Phone number *

Multiple treatments per week, in the first number of weeks of treatment, is necessary with Dr. Vodder's Manual Lymphatic Drainage massage. Are you prepared to make that time commitment? *

Do you have history of Congestive heart failure?

Do you currently have blood clots?

Do you have a history of blood clots?

What are your reasons for coming for treatment?

Are you seeking pre operative cosmetic surgery treatment?

Are you seeking post operative cosmetic surgery treatment?

Do you currently have any infection?

Are you on antibiotics?

If I have availability in my clinic schedule, what is the best number number to contact you at?

When is the best time of day to contact you?

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms