Massage Consent

Name*

Birth Date*

Date

Phone*

Email*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you had a professional massage before?*

YesNo

Which pressure do you prefer?*

LightMediumDeep (+$10)

Are there any areas that you do not want massaged? (feet, face, etc.)*

YesNo

If yes, please list:

Do you have any allergies, sensitivities, illnesses, injuries, chronic pain, or other medical conditions that may affect your treatment?*

YesNo

If yes, please list:

Are you currently pregnant?*

YesNo

If yes, how far along? *Massage is not offered in the first trimester.

General Liability Release

By signing below, I agree to the following:

1. I give my permission to receive massage therapy.

2. I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.

3. I understand that Jamie Kowalski does not diagnose illnesses or injuries, or prescribe medications.

4. I have clearance from my physician to receive massage therapy.

5. I understand the risks associated with massage therapy include, but are not limited to: superficial bruising, short-term muscle soreness, and exacerbation of undiscovered injury. I therefore release Jamie Kowalski from all liability concerning injuries that may occur during the massage session.

6. I understand the importance of informing Jamie Kowalski of all medical conditions and medications I am taking, and to let her know about any changes to these. I understand that there may be additional risks based on my physical condition.

7. I understand that it is my responsibility to inform Jamie Kowalski of any discomfort I may feel during the massage session so she may adjust accordingly.

8. I understand that I or Jamie Kowalski may terminate the session at any time.

9. I have been given a chance to ask questions about the massage therapy session and my questions have been answered.

Signature*

Date*

Date

Massage Consent Form