New Massage Client Liability Consent Form after September 4th 2023 & revised February 29 2024 Logo
  • The Massage Negotiator Client Liability Form :

    Required by law to massage over the age of 18 (or with separate consent form for massage of a minor), keep progressive reports of clients, protect this information by HIPPA/HIPAA regulations, maintain these client details to prevent massage and bodywork contraindications. An assessment that fully details the modalities and services provided for that session, the appointment date, time of appointment, suggestions for maintaining health and wellness and for your next massage appointment are filled in by your massage therapist and emailed to you after every appointment in 0-7 days (not required by law). You must fill in a new form every 1-2 years for any unforeseen health conditions or limitations you might need to change for your subsequent massage sessions. All massage sessions are customizable and accommodating to any new changes you might experience. After filling out this form you will receive a copy at the email you provided for your records.
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  • Please read the following Terms and Agreements and sign your name after reading each item below about your massage session.

     

  • Terms and Agreements for mobile massage services:

    1. All mobile massage services include the first 1/2 hour drive time from Corona where the 15 freeway and the 91 freeway meet in the historical time marked by Google maps. If you live only 10 miles away, it might not be less than 30 minutes away if it is during a high traffic time that makes the commute 20-45 minutes longer. If your scheduled massage does take longer than the 30 minutes to drive to the massage address or more than 30 minutes on the way back there is a $20/30 minutes fee added to the service.

    2. The correct address must be given to the massage address where the scheduled massage is to be done. If the address is not marked accurately or does not have the building in an apartment complex, the appointment is cancelled for safety concerns and a transportation fee of $40 for the appointment is assessed to the card on file.

    3. Offensive language or body language that is inappropriate and makes the massage therapist uncomfortable or feel disrespected for Title IX basic human protected rights (discrimination for race, religion, gender, sexual preference, sexual identity, disability, age greater than 40 years), or class status, or nationality status, sexually or violently offensive language is not allowed or tolerated. 

    4. Please be ready for the massage 15 minutes before the scheduled time as this is a mobile massage service and traffic can be underestimated, but also time to set up equipment is necessary. If the massage is late up to 15 minutes beyond the scheduled start time and the Google maps history of estimated travel times says it should have been on time from the 91 freeway and the 15 freeway intersection in Corona, CA at the day of the week, holiday, and time, then you get $20 off your massage. Otherwise, if Google maps says the travel distance at that time historically leaving 30 minutes before the start time took longer than 30 minutes, than rule/item 1 above applies to Terms and agreement for mobile massage services. 

    5. If stairs are used in the home address, the lighter massage table that is narrower will be used. If the home address listed appointments has a first floor setting, then the wider massage table will be used. We recently purchased a much lighter, wide table that allows stairs and more comfort for clients. If a deep tissue massage is needed, the table will have to be set manually by unfastening and then refastening a hand screw in double safety measure. This can be about 5 minutes to do, but shouldn't impact time from massage if allowed to set up early.

    6. If using any add on services for therapeutic benefits of massage and an electrical outlet is needed to perform the service, such as for infrared light therapy, hot stones, hot towel warmer, table warmer, etc. and the service address does not have the available electrical outlet, then the service can not be provided nor will be charged nor any discount assessed if bundled in a massage promotional package. 

    7. Parking must be available in front of the address, or in the apartment complex, and the distance from the public parking to the massage address will be acknowledged and also time deducted from the allowed 30 minutes delivery of massage supplies to the scheduled massage appointment if the walk is a 10 minute walk for example, and not easily able to be found by building and/or floor number also requiring an elevator. If parking is not available close to or in front of the house, or the street is unsafe or not a wide street that allows cars to park on the sides and two cars able to travel in both directions along the street in front of the house with room and without one car having to stop to wait for the other car to cross before traveling down the street, then the appointment will be cancelled, and a $20 transportation for massage therapist's time will be assessed, plus any estimated transportation and delivery fees if the appointment was realized to be more than 30 minutes to and/or from the scheduled appointment. 

    8. Offensive settings or people in or around the massage therapist providing massage services at the massage address should be zero to minimal and in other room so that nobody bothers the massage therapist while delivering the massage to the guest, or plays with the client receiving a massage while the massage therapist is providing massage such as tickling the person or grabbing the client's body part while said client receives a massage. The massage will be terminated as it is unprofessional and makes the massage therapist feel uncomfortable and is a violation of inappropriate touch during the massage session by a professionally state association for massage therapy licensed, massage standards certification educated, and city of origin business licensed massage therapist. The client will feel uncomfortable and it would be difficult for the client at that time to trust the massage environment is going to be a relaxing one and trust the benefits of massage when another person or guest is distracting the client on the table.

    9. If the client needs to talk on the phone during the massage, it comes from the massage time scheduled, but it is better to schedule a time that fits the client's budget and the time needed and set aside to receive a quiet and peaceful massage.

    10. Pets are allowed to be nearby as long as they don't chew or pee on the massage table and supplies, or bite the massage therapist.

    11. Time to set up and time to disinfect and put away massage supplies and gratuity is included in all massage appointment prices and packages, if you want to add more for gratuity it will have to be cash or Zelle.

    12. Only credit card or Zelle are acceptable forms of payment for booking mobile massage services. We recently started accepting Spa Finder book cards and if you have the multi-use (the one without a pin code), then you can book your massage with deposit and pay for services with that gift card on regular priced services as discount provided to partner affiliate. The single use Spa Finder gift cards have a pin code and can be used for the service but cannot be refunded and to book the appointment with a deposit will require the non-refundable fee paid for with credit card.

    13. Any massage address booked at a location that is more than 30 minutes of drive time according to Google Maps estimated travel time from the 91 freeway and 15 freeway in Corona, CA is paid for up front as $20/30 minutes to and from blocks past the given 30 minutes drive time including traffic according to google map estimated drive times. 

    14. All massage clients receiving a massage at the massage address have to agree to these Terms and Agreements and fill out this massage client intake form. Unless, a group setting for workplace wellness or event at home for special occasion. In that case, there would be a list for each person receiving a massage on chair and/or table to sign name, phone number, DOB, and date that gives consent to perform massage services and clarifies understanding of massage benefits and contraindications.

    15. Any minors receiving a massage must have a form of permission from the legal guardian and/or parent that the minor may receive a massage. Minors may not be able to receive a full hour massage and the parent must be in the room or monitoring the massage in progress start to end. No more than medium pressure will be used, undergarments will be on and the upper thigh and abdomen and chest avoided in the massage of minor by massage therapist.

    16. If you don't pass the biopsychosocial model for pain and mental health, you may not be allowed a massage for your aches and pains until you see a psychotherapist or counselor who approves you for massage to help with you aches and pains. You may also be advised on the pain gait theory of pain and how having any emotional or altered state of mind affects how the pain, touch, temperature, pressure, and proprioceptors of tickle and itch are perceived in the brain. This is due to the thalamus of the brain interpreting and sending out actions to all sensory except smell. Smell is tied to memory and emotion in the limbic system and you would have to purchase the $5 add-on of aromatherapy of choices Lavendar, Eucalyptus, Lemon Grass, Sweet Orange, Spearmint, Peppermint, or other aromatherapy available.

    17. Please note that social media works both ways, if you leave a negative review of my business other than none, you will be not be refunded and will have our version of the details posted in response. By posting online of your experience by your massage therapist you waive your rights to privacy and discretionary rights to how the service was handled. Identifiable details such as service address, age, and full name will not be posted unless a criminal offense was done against our massage therapist so that we may inform the public as our obligated duty as professionals in the service industry of complementary alternative medicine (CAM) professions.

    18. Due to social media trolls and such on various marketing sites, any type of settings that make a massage therapist uncomfortable or feel disrespected or unsafe will lead to immediate cancellation of the appointment. Full charge of the massage not re-imbursed, and an online notification to the social network circles of the details of the offender, date, location, and description of the offensive scenario or event. Even being off by one digit in the service address is inclusive of this item terms.

    19. Most of these items are common sense, but they are necessary to provide a safe environment that promotes courtesy and respect, free from noise or other nonsense, to deliver the therapeutic and peaceful massage services we provide.

    20. Workplace massage for wellness or events of special occasions where the format of delivery for massage services is within a few hours and many people can get 5-15 minutes of massage each while remaining fully clothed are now available. This is a great way to offer wellness and stress relief to those you care about. The use of alcohol by employees is allowed as long as not showing signs of intoxication, being sick, or offensive. Only at events where no to max of 2 drinks per person are allowed for the group massage events.

    21. When receiving a massage it is important to communicate with massage therapist on pressure, if too much or not enough, if you are feeling unwell, or any other needs to technique or modality. Please do not try to criticize the style or be offensive to massage therapist when communicating the modality or technique or even pressure to use and tools of hands, fingers, elbows, knuckles to use. We understand that very few people have a specific flow and style of massage delivery, and we are capable of delivering similar and even the same if communicated respectably. 

    22. Generally massage can feel relaxing and/or energizing to each person, with some who may feel sore or very sore the next day or two. Recommendations to not get deep tissue or grin and bear it through painful massage applications if someone wants you to get deep tissue and hurt you intentionally or if you want to experience the same deep pressure and body work as others but are in a lot of pain from not having a massage in a long time or having very intense heavy weight lifting workouts that already breakdown muscle tissues regularly. Our goal is not to cause pain, and to work out adhesion lesion knots in muscles, tendons, myofascial, and other soft tissue musculoskeletal body structures that could be causing peripheral nerve compression, ischemia to muscles, and general aches.

    23. Please notify your massage therapist of any health conditions you have to determine if massage or local massage to area is contraindicated. If you cannot feel the pressure and want more that cannot be delivered, then understand that opioids affect the pain receptors in chronic pain patterns but not the nagging pain and noxious stimulus fibers that communicate discomfort. Thus, if you are on opioids like vicodin, norcos, oxycodone, etc., your sensorycortex interpretation of pain will not be the same as others and any type of pressure applied travels on the dorsal horns of the spinalthalamic tract, and is inhibited at the cortical level. Massage won't work to cure that 'nagging' old pain if on opioids. You will be relieved of the pain if you choose to detox the opioids from your body first, to rewire the neuroplasticity of crossed nerve fibers. Massage can help in that phase to build neuroplastic communications that grow healthy nerve fibers from existing axonal neurons intact to affect tickle, itch, deep pressure, skin point discrimination, proprioception, and balance from being effected by miscommunication of pain in old injuries that haven't healed properly in chronic conditions of pain. It takes time, regular massage, and cognitive behavioral therapy, along with a committment by that person to be on a wellness plan to heal.

    24. Each person experiences pain and sensory different, systemic affects on the body can cause peripheral nerve compression and postural changes that affect the body negatively and can lead to long term pain patterns and reactions to stress that becomes a viscious cycle of pain and more pain and discomfort perpetuating even more pain and discomfot that needs intervention by following a holistic health plan including massage, exercise, cognitive behavioral therapy, diet, nutrition, sleep, meditation, deep breathing exercises, stretching, and postural corrections to daily tasks as well as rehab resistance training.

    25. Patient autonomity is a virtue of healthcare providers, and you are a patient if you under the care of your medical doctor or other recognized doctors such as doctor of chiropractic or acupuncture alternative medicines. The CAMTC board regulating massage therapy does not recognize massage patrons as patients but having the state license makes massage therapists healthcare providers and thus massage patrons patients if under the active treatment and management of a physician but only clients if only seeking massage for managing stress, pain, stretching, or other physiotherapy modalities. Any advice you get from your massage therapist is not a diagnosis but a suggestion based on the Merck Manual of gold standard diagnostics that allows you to have all information available to make informed decisions and understand your healthcare and physical condition and limitations. You can purchase a Merck Manual online for under $100 for the most recent up to date edition and get an online app for free for humans and veterinarian medicine. You understand any advice is a suggestion to get a condition ruled out and practice patient autonomity for your health and a referral to another physician or specialist such as gastroenterologist, rheumatologist, endocrinologist, orthopedic surgeon, neurologist, or neurosurgeon is up to you to pursue and investigate your health and prevent further progression of pathology or treat it if a positive sign or present sign for a musculoskeletal or visceral physical exam in part or full shows signs or symptoms of a specific or multiple pathologies.

     

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  • Thank you for filling out your liability and consent to have massage therapy services by The Massage Negotiator. You can save the form now and email janis@themassagenegotiator.com a copy or continue filling out the optional customization of your first massage session on this form. You can also submit it as is if all required fields are filled in by clicking submit below.

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  • Customization of Massage Session for First Time Clients



  • For the below selection, you can find additional information on the requirements for each massage package by visiting: service information.

  • Thank you for your time filling out this form. We look forward to providing you with massage services at your scheduled massage appointment address.

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