Massage Therapy Consent Form
Client Information
Name
First Name
Last Name
Insurance information
Group number -
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Type of massage
SWEDISH MASSAGE
DEEP TISSUE MASSAGE
ORTHOPEDIC MASSAGE
BOOK AROMA THERAPY MASSAGE
BOOK THERAGUN MASSAGE
CHAIR MASSAGE
TABLE MASSAGE
Desired DATE AND TIME of massage
Example: Monday 1/1 after 3 pm - Tuesday or Thursday AM. After completing this form I will reach out to complete your massage booking process.
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Health Data
Location of painful areas
Reason for this massage
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you currently pregnant or nursing
Yes, pregnant.
Yes, nursing.
No
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Cancellation Policy
All scheduled therapy and massage sessions must be cancelled 24 hours before your scheduled time. Any cancellations or no-shows will result in a $30 charge to the credit card on file.If for some reason your trainer needs to cancel your session within 24 hours of your scheduled time, you will have 15 minutes free added to your next scheduled session. We appreciate your business & understanding!
Consent and Waiver
I authorize this massage spa clinic/center to perform the treatment or necessary procedure for my child.
I authorize the use of lotion, oil, and ointments to my body.
I acknowledge that I have consulted a physician before undergoing this massage treatment.
I release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Client
Clear
Date Signed
-
Month
-
Day
Year
Date
Submit
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