MT Consent Form

Massage Therapy Consent Form
Client Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number

Area CodePhone Number
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

Area CodePhone Number
Relationship
Health Data
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? (Female only)
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
Important information regarding the Coronavirus (Covid-19)
Lympha Spa and Massage is taking the recent virus outbreak along with the security and peace of mind of our staff and clients very seriously. We are continuing to maintain a high level of awareness and cleanliness within our establishment based on our existing principles as well as using accurate and up to date information coming from the CDC and WHO. If you are showing symptoms of a cold/contagion or flu like symptoms, please stay home until you are fully recovered. Also, if you have recently traveled within the US or abroad near hot spots, please give yourself at least 2 weeks to monitor for possible infection. Here is a map of the outbreaks around the world which will help you determine if you fit that category:

https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

Massage Policies:

Client services and chart information are confidential. Written authorization is required from you to release any information.

       • Please turn off your cell phone for optimal relaxation

       • Your scheduled session is set aside for you. We do not double book appointments

       • Please reschedule your session if you are more than 15 minutes late

       • 24 hour cancellation notice is required to avoid being charged for your session

       • You will be draped and at no time will genitalia or breast tissue be exposed

       • You will have a consultation with your therapist to discuss your session

       • Should the session require, after your therapist has left the room, you may disrobe to your comfort level

       • I understand that my therapeutic massage therapist or I may end the session at any time for any reason

       • Inappropriate behavior will not be tolerated and may be prosecuted to the full extent of the law

Client Agreement:

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization.

I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

It is my choice to receive therapeutic massage as a form of therapy.

I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction.

I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust.

I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status.

I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Pure Touch Therapy and my therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Signature of the Client

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Massage Therapy Consent Form

Client Information

Emergency Contact Details

Health Data