Massage Therapy Consent Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
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Month
-
Day
Year
Date
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
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 pregnant or nursing? (Female only)
If yes, please specify on the field above.
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
I authorize Creating Balance to perform the treatment or necessary procedure for me.
I authorize the use of lotion, oil, and ointments to my body.
*I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician. *ONLY necessary if contraindications
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release Creating Balance for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided int his form is true and accurate.
I authorize and grant Creating Balance to take my photos regarding my experiences with them.
I grant Creating Balance to use my photos on Facebook, Twitter, Instagram, and other social media platform.
I allow Creating Balance to edit, alter, copy, or distribute the photos for social media advertising and marketing.
I agree that the photos belong to Creating Balance, and I understand that I will not receive any monetary compensation.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: