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ReNew Life Creations

Female Client Intake & Consent Form

Clientâ&#x20AC;&#x2122;s Informed Consent Essential Oil Therapy during Cancer Treatment Print Name _______________________________________________ Date ___________________________ What discomforts, pain or other needs are you hoping to have addressed through therapy? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ List the Name and Phone of your Primary Caregiver: ___________________________________________________________ Is your body temperature usually: __ Hot __ Cold __ Neutral Are you comfortable lying: __ On Left Side __ On Right Side __ On your Back __ Slightly sitting up (as in bed) __ On your stomach Do you currently have any infections or problems? __ Cold/Flu __ Infection __ Skin Irritation List Other ____________________________________________________________________________________ When were you diagnosed with cancer? __________________________________________________________________ What stage is your cancer now? __ Unknown __ One Remission __ Two Remissions __ Three Remissions __ Four Remissions What body structures have or are suspected to have cancer involvement at this time? Brain Bones Gallbladder Skin Ovary Lymph Esophagus Liver Colon Small Intestine Uterus Lungs Stomach Prostate Cervix Other______________________ Heart Pancreas Testes Breast _________________________ What type of treatment are you going through now (or within the last 3 months)? Chemotherapy Radiation

Blood Transfusion Hormone Therapy

Surgery Sentinel Node Biopsy

What type of treatment have you had in the past? ____________________________________________________________ What are the side effects of these treatments? ______________________________________________________________ __________________________________________________________________________________________ Do you have any areas that should be avoided, such as catheters, tumors, or radiation burns? __________________________________ Do you have Lymphedema or symptoms of Lymphedema?

Yes

Is there any other relevant information about you that I should know? ________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ For Office Use Only MT: _________ F/U Date: _________ TYC Date: _________ Scan Upload MBOinput

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ReNew Life Creations

Female Client Intake & Consent Form

Clientâ&#x20AC;&#x2122;s Informed Consent Essential Oil Therapy during Cancer Treatment

Print Client name: _______________________________________________________________________________ When used as a form of adjunctive health care, some of the possible benefits during cancer treatment are: 1. Reduction of stress and promotion of relaxation through physical nurturance and emotional support 2. Increased blood and lymph circulation, and support for the immune system 3. Facilitation of respiratory, gastrointestinal, hormonal, and other physiological processes 4. Reduction of musculo-skeletal strain and pain, especially in the back and neck 5. Facilitation of the removal of toxins from the body, including edema 6. Restoration of energy by minimizing the side effects of radiation and chemotherapy treatments including fatigue, nausea, joint pain, and anxiety 7. Enhancement of body awareness and encouragement to direct energy toward healing 8. Facilitation of the functional formation of scar tissue around surgical areas, and 9. Improvement in quality and appearance of skin 10. Acceptance of a new body image after surgery and/or during treatment Potential complications of EOT during cancer treatment and conditions which would contraindicate EOT (unless a physicians release is received): 1. Metastasis (spread) of cancer cells from one area of the body to another before and during active treatment 2. Bruising of body structures due to low platelet counts 3. Displacement of catheter 4. Aggravation of irritated skin 5. Increase in nausea, fatigue or swelling I, the client, understand that the Essential Oil Treatment, hereby EOT, as provided by ReNew Life Creations is intended to achieve the above mentioned benefits, and offer a positive experience of touch. I also recognize the risks involved. Any other intended purposes for EOT not listed above are specified below:

_________________________________________________________________

The general benefits of EOT, possible risks and contraindications, and the treatment procedure have been explained to me. I choose to accept EOT therapy because I have evaluated my situation and consulted with my Primary Caregiver where I thought it necessary, and I have decided that the potential benefits outweigh the risks. I understand that EOT is not a substitute for medical treatment or medication, and that it is recommended that I concurrently work with my Primary Caregiver for any condition I may have. I am aware that the EOT therapist does not diagnose illness or disease, doses not prescribe medication, and that spinal manipulations are not part of EOT therapy. I have informed the therapist of all my known physical conditions and medications, and it is my responsibility to keep the therapist informed of any changes. Should the therapist deem it necessary, I hereby give the therapist permission to contact my Primary Caregiver to discuss my medical situation with the intention of obtaining a release for medical treatment. Client Signature ____________________________________________ Date _____________________ Parent/Guardian ____________________________________________

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ReNew Life Creations

Female Client Intake & Consent Form

INFORMED CONSENT FOR LYMPH GLAND THERAPY AND/OR TREATMENT Under NRS 640C.700(4)(c) Grounds for disciplinary action include massaging, touching or applying any instrument to the breasts of the person unless the person has signed a written consent form provided by the Board. When the treatment of sensitive areas is indicated during the course of a Essential Oil Treatment/therapy, it is important that you, the client, fully understand the nature and purpose of this treatment. In addition to our discussion about the treatment, this written consent form will act as a record of that discussion. If you have any questions, either during our discussion or while completing this form, please do not hesitate to ask. I, ___________________________________________________________, am voluntarily wishing to experience a session of lymph gland therapy, for the purpose for which is intended: recovery from surgery, scar improvement, medical breast massage. I have discussed the treatment and/or treatment plan with Martin Riding of ReNew Life Creations. During this discussion, the benefits, risks and side effects, areas to be treated, positioning and draping (covering)to be used near the treatment area have been explained to me. I understand the treatment area of skin must be laid bear to absorb the full potential of Essential Oil Treatment (EOT).. I have had the opportunity to ask questions about the above information and I know that I can ask any questions that I have, as a result of the treatment or further discussion, at a later date. As with any aspect of EOT, if at any time I feel uncomfortable for any reason, I will ask the therapist to cease the treatment and the therapist will end either the lymph gland therapy or the EOT. I understand it is at my discretion to have another woman or family member (husband or partner) present during any session. I understand that the nipples and areolas of my breasts will not be touched at any time during the treatment. There are various levels of comfort in receiving breast massage. I am checking the statements that I feel comfortable with:

* Note: Oils cannot be applied through clothing. ____ I would like the therapist to demonstrate the breast massage technique for me while wearing a T-shirt. ____ I would like to remain clothed or draped and have the therapist work with me through clothing or draping:

Clothed

Draped

____ I am comfortable having the therapist work under the draping with the hands directly on the breast while performing EOT. ____ I am comfortable having the therapist work with the hands directly on the uncovered breasts while performing EOT. I understand that I can alter or withdraw my consent for this treatment and/or treatment plan at any time during this or any other treatment. Client Signature: ____________________________________________

Date: ____________________

Therapist Signature: __________________________________________

Date: ____________________

Please retain this record as instructed under NRS 629.051