Massage Therapy Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

First NameLast Name

Phone Number

Area CodePhone Number

Occupation:

Have you had a professional massage before?

YesNo

What pressure do you prefer?

LightMediumFirm

Check all that apply:

Any recent surgery or injury in the last 6 - 12 months?

YesNo

If yes, please describe:

Any allergy or sensitivity to essential oils?

Please list any other allergies or sensitivities you would like me to know about:

Are you pregnant? **Client MUST be beyond first trimester to receive massage**

YesNo

Do you have cancer? **Clients recently diagnosed with cancer or clients currently going through treatment MUST provide doctors note before receiving massage**

YesNo

Have you EVER had ANY Lymph Node radiation, removal OR biopsy? ** Any lymph nodes that have been compromised are contraindicated for massage. For a client to receive massage in an area of the body with compromised lymph nodes they must first acquire a doctors note.

YesNo

What are your massage goals of the day? Check all that apply:

RelaxationPain ReliefPreventative Health

Do you have any skin conditions today?

I further understand that massage or bodywork should not be constructed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all the questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on Bliss Studio & Spa LLC or their licensed massage therapists should I fail to do so.

CLIENT NOTES

Signature

Date