Under Arizona State Board of Massage Therapy Statute Chapter 42, 32-4253: Grounds for disciplinary action include massaging, touching or applying any instrument or device by a licensee in the course of practicing or engaging in massage therapy to the breasts of a female client unless the client requests breast massage and signs a written consent

When the treatment of sensitive areas is indicated during the course of a massage therapy treatment, it is important that you, the client, fully understand the nature and purpose of this treatment. In addition to our discussion about the treatment, this written consent form will act as a record of that discussion. If you have any questions, either during our discussion or while completing this form, please do not hesitate to ask.

I, the undersigned client, am voluntarily requesting to experience a session of breast massage, for the purpose which it is intended (i.e. recovery from surgery, scar improvement, medical breast massage

I have discussed the treatment and/or treatment plan with the practitioner, John Mistalski. During this discussion, the benefits, risks and side effects, areas to be treated, positioning and draping (covering) to be used have been explained to me. I have had the opportunity to ask questions about the above information and I know that I can ask any questions that I have, as a result of the treatment or further discussion, at a later date.

As with any other part of massage therapy treatment, if at any time I feel uncomfortable for any reason, I will ask the therapist to cease the massage and the therapist will end the treatment.

I understand that the nipples and areolas of my breasts may be touched during the treatment.

There are various levels of comfort in receiving breast massage. If I have any questions, concerns, or requests regarding the following statements, I will inform the practitioner during, before, or after the breast massage session:

I would like the therapist to demonstrate the breast massage technique for me while wearing a shirt.

I would like to remain clothed or draped and have the therapist work with me through clothing or draping.

I am comfortable having the therapist work under the draping with the hands directly on the breast while performing massage.

I am comfortable having the therapist work with his hands directly on my uncovered breasts while performing

I understand that I can alter or withdraw my consent for this treatment and/or treatment plan at any time during this or any other treatment.