RUTH ASHLEY LEWING, LMT
Tel. (206) 920 6978 firstname.lastname@example.org Fax (206) 632-4010
PHYSICIAN APPROVAL FORM FOR CLIENTS WITH CANCER DIAGNOSIS
Your patient, __________________________________, has expressed interest in receiving massage therapy during the course of her/his cancer treatment. I am writing to you to
Common Adaptations for Clients in Cancer Treatment:
Sites affected by surgery, radiation therapy, IVs, drains, skin conditions pain, edema or bone involvement.
I will avoid these sites. If there is any nodal involvement with risk of lymphedema, we will use no pressure on the distal extremity and use gentle pressure on the trunk quadrant. I have been trained in lymphedema management and combined decongestive therapy by the
Low platelet counts; easy bruising.
I will use gentle strokes that displace only skin and superficial tissues, not deep muscle layers.
Side-effects of treatments such as chemotherapy and radiation therapy.
I will work gently in order to avoid aggravating fatigue, nausea, etc. and will adapt other elements of the session to any presenting side-effects.
Any risk of deep vein thrombosis secondary to malignancy, inactivity or cancer treatment.
I will avoid pressure on the lower extremities if there is any risk of thrombosis in those areas.
__________________________has my permission to receive relaxation massage described above.
I’ve read through the common massage therapy adjustments above. I have circled any concerns for this patient. If I have any additional concerns for the massage practitioner, I have described them below:
Physician’s Signature Date
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