RMT Consent - Sensitive Areas

Consent for Assessment and Treatment of Sensitive Areas

I,
Name*

First NameLast Name
have requested assessment/treatment by thisRegistered Massage Therapist (RMT),
RMT Name*

First NameLast Name
As part of my therapeutic assessment and treatment, I am aware that the above named RMT will assess/ treat the following area(s) of my body.

[Breast(s), Chest wall muscles, Inner thighs, Buttocks]
Area(s) to assess/treat
Initials*
The RMT has explained the following to me and I fully understand the proposed assessment and treatment, including:
- The nature of the assessment and/or treatment, including the clinical reasons to assess/ treat the above area(s) and the draping methods to be used
- The expected benefits of the assessment and/or treatment
- The potential risks of the assessment and/or treatment
- The potential side effects of the assessment and/or treatment
- That consent is voluntary and I can withdraw or alter my consent at any time
I voluntarily give my informed consent for the assessment and/or treatment as discussed and
Initials*

Clear
Client's name*
Client's signature*

Clear
Date*

MonthDayYear
Date
RMT signature*

Clear
Clinical Indication
Should be Empty: