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
INFORMED CONSENT TO MASSAGE THERAPY TREATMENT
I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by the Massage Therapist Association of Saskatchewan, Inc.
I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such assessments, examinations and techniques, which may be recommended, by my therapist.
I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks.
I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have completed my medical history form as provided by my therapist and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge.
I authorize my therapist to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third party payers.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
COVID-19 WAIVER / RELEASE
I acknowledge that Preston Schaffer (the “Therapist”), in
returning to work, has confirmed to me that he/she has adhered to all health standards and guidelines set out by the Government of Saskatchewan relating to COVID 19.
The Therapist has confirmed to me that they have complied with all hygiene and practice standards
imposed by the Massage Therapist Association of Saskatchewan (MTAS). Notwithstanding the Therapist
has complied with Personal Protection Equipment requirements and complies with the appropriate
guidelines, the Therapist cannot guarantee there will be no contraction of COVID 19 arising out of
treatment.
This form constitutes a release and waiver of the Therapist from liability should COVID 19 be contracted
through treatment. I acknowledge I have been requested to execute this release and it is a condition of
my receiving treatment from the Therapist, and failure to execute this Waiver and Release may result in
treatment being refused.
1. I ACKNOWLEDGE and AGREE I understand the nature of the treatment I have requested;
2. I CONFIRM I am not currently showing any symptoms of COVID 19, and I have not, to my
knowledge, contracted COVID 19, and I am aware of the COVID 19 symptoms.
3. I HEREBY RELEASE, WAIVE and DISCHARGE the Therapist, his/her administrators, employees,
officers, agents, successors, heirs and assigns from all liability, actions, demands, and proceedings
arising from my contracting COVID 19 as a result of my treatment.
4. I ACKNOWLEDGE I have read this Waiver and Release and fully understand its terms and I have
signed it freely and without any inducement or assurance of any nature; and I intend it to be a
complete and unconditional release of all liability to the greatest extent allowed by law
relating to my contracting COVID 19 from treatment.
If any portion of this Waiver and Release is
held to be invalid, the balance, notwithstanding, shall continue in full force and effect.
This Waiver and Release shall be governed by and construed under the laws of the Province of
Saskatchewan.
By my electronic signature below, I agree to the massage policy Covid-19 Waiver, and client agreement above.