Massage Therapy Consent

Massage Therapy Consent Form

Please fill out and submit before your massage.
Full Name

First NameLast Name
Phone Number
Email
example@example.com
Date of Birth

MonthDayYear
What is your Main Concern for booking your massage?
Did someone refer you?

YesNo
If Yes, who? If No, how did you discover Authentic Bodywork?
I, {fullName64}, hereby consent to the massage therapy and other massage procedures such as stretching and other tools.

I acknowledge that I have the right to discuss the nature of treatment, treatment procedures and my health condition with the therapist.

I understand that therapeutic massage therapy does not diagnose and heal illness, disease, any physical or mental disorder. Massage therapy is not a substitute for medical examination. I understand that this treatment is designed to address the care and prevention of myofascial pain and dysfunction.

I understand that there can be risks to treatment, including but not limited to, tenderness, bruising, light headedness or dizziness which I do not expect all risks and complications to be explained before the treatment and I wish to rely on the judgement of my massage therapist regarding any risk management. Also, at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist.

I understand that I will be draped at all times and the areas undraped will be secure to insure there is no indecent exposure.

I will also have the privacy to undress/dressed and the therapist will knock and wait for my reply upon entering.

By my electronic signature below, I, {fullName64}, agree to the massage policy and client agreement above.
Signature*

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Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Date

MonthDayYear
Should be Empty:

Massage Therapy Consent Form