Massage Therapy Consent Form

Massage Therapy Consent Form
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship
Health Data
How did you hear about Mysa Skin and Body Studio?
Other/Referral name:
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing?
If yes, please specify on the field above.
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Location of painful areas
Massage specifics
What is your goal for this massage?
Requested pressure
Areas of consent. Please select all areas confirming you consent for allowing them to be massaged.
Are there any other areas you would like to avoid during this session?
What area(s) would you like the most attention to?
Consent and Waiver
Will you allow for photos to be taken and used for social media?
Signature of the Client
Date Signed

MonthDayYear
Date
Should be Empty:

Massage Therapy Consent Form

Client Information

Emergency Contact Details

Health Data

Massage specifics

Consent and Waiver