Consultation and Treatment Consent Forms

Thank you for recently booking your appointment with LymphVision. Before we see you on the day, please take the time to complete the following documents. If you have any questions about this process we would be happy to hear from you. You can reach us at: clinic@lymphvision.com or 0300 180 0112.

Consent to consultation, examination, MLD and general lymphoedema treatment.

I approve and direct, Mrs Jane Wigg, or an associated healthcare practitioner, to perform Manual Lymphatic Drainage (MLD) and other general lymphoedema treatment for which they practitioner is qualified in (including but not restricted to: bandaging, compression, kinesiotaping, Intermittent Pneumatic Compression (IPC), positioning and exercises, Photobiomodulation (PBM)/laser therapy).

CONTRAINDICATIONS:

I understand that complete contraindications to the treatment are:

1. Any metastatic or systemic malignant condition.

2. Untreated acute heart problems and renal failure.

3. History of thrombosis (DVT) or tuberculosis.

MLD cannot be performed:

1. While undergoing active cancer treatment, such as chemotherapy or radiotherapy

2. During an acute infection (such as cellulitis)

3. During pregnancy

Precautions are required if MLD is used in the following conditions which should be disclosed to your clinician and discussed in advance of treatment:

• Oedema following carcinoma treatment

• Thyroid dysfunction

• Chronic inflammation

• Bronchial asthma

• Hypotension

• Oedema caused by cardiac decompensation

• Diabetes

RISKS AND SIDE EFFECTS:

MLD is regarded as a very low risk treatment and side effects are minimal. Very few people have negative reactions to lymphatic drainage massage.

Short term reported side effects include:

• Headaches

• Nausea

• Fatigue

Long term, more serious side effects are rarely reported but can included:

• Increase in swelling (due to underlying/undiagnosed cause)

DISCLAIMER:

I have read and understand this consent form.

1. I do not currently have any medical condition listed above which will affect treatment.

2. I accept and consent for MLD and other lymphoedema treatments to be used in this way.

3. I understand and accept these risks.

4. All my questions have been satisfactorily answered.

5. I have been given all the information I asked for about the procedure(s), risks, and other options.

Consent to Data Storage

The data contained in this form and other forms I complete or completed on my behalf will be processed and stored securely by Lymphvision Ltd in accordance with the company’s ‘Data Security Policy’ and ‘Privacy Notice’, and in line with current regulation. LymphVision will never sell or share your data to any other party. LymphVision may pass your data on to a specified medical professional or clinical team only at your request or with your consent.

Please confirm that you consent to LymphVision storing the personal Data you have provided them with.