Electro-Lymphatic Therapy Forms Fields marked with an * are required First Name * Last Name * Address * City * US States * - Select State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC ARMED FORCES AFRICA \ CANADA \ EUROPE \ MIDDLE EAST ARMED FORCES AMERICA (EXCEPT CANADA) ARMED FORCES PACIFIC Zip * Phone * Email * Date of Birth * Divider Are you on blood thinner? Are you pregnant or do you think you could be pregnant? Do you have or have you ever had thrombosis or bloodt clots? Do you have any open wounds or sores? Have you ever had an organ transplant? Do you have cellulitis? (NOT cellulite) Have you ever had seizures? Do you have a kidney ailment? Have you ever had plastic surgery? If yes, please detail what type. Do you have any type of medical device for the heart? (e.g. pacemaker) Divider Please select any of the following conditions that apply: Emotional Changes Lyme Disease Flu (currently) Ulcerated Colon Neck/Spine Injury Cancer Fever (currently) Elevated Cholesterol Infectious Conditions Osteoporosis Allergies Pregnancy (currently) Acute Pain Kidney Ailment Varicose Veins P.M.S. Syndrome Chronic Pain Phlebitis Heart Ailment High Blood Pressure TMJ Syndrome Sports Injury Skin Disorders Migraine Chest Pain Diabetes Fibromyalgia Grief Process Accidental Injury Any other condition not listed If you have any other conditions not listed, please list them here. Divider Please select any of these products you use that are not natural: Deodorant Sunblock Spray Tan Body Lotions/Oils Hair Products Divider Please state any recent or past injuries or medical treatments: Please state all surgeries: (this is very important for determining the correct routing of drainage) Divider Are you currently under the care of a health professional? If yes, please list health provider's name and phone number: Divider Please list an emergency contact: (name, relationship, phone number) If you are a human seeing this field, please leave it empty.