Massage Consent Form
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Date of birth
Referred by (name)
List all sports & activities you are involved in:
Do you have a peanut allergy?
I don't know
List all known allergies
Are you under medical care for any of the following:
Headaches / migraines
Jaw or ear pain
High blood pressure
Low blood pressure
Phlebitis /circulatory problems
Pelvic inflammatory disease
Have you received treatment from any of the following:
Reason for treatment:
Have you had surgery in the past year?
If yes, for what?
Have you had any fractures / sprains in the past year?
If yes, what?
Have you had any serious illnesses in the past year?
If yes, what?
By typing my name below, I understand that the massage therapist is providing massage therapy services within their scope of practice. I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including such assessments, examinations & techniques, which may be recommended by my therapist. I acknowledge that the therapist is not a physician & does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with my treatment there can be risks & i assume those risks. I acknowledge & understand that the therapist must be fully aware of my existing medical conditions. I have completed my history form as provided & disclosed all of the medical conditions affecting me. It is my responsibility to keep the therapist updated on my medical history. The information I have provided is true & complete to the best of my knowledge.
By typing my name below, I acknowledge that I have read the above noted consent & I have had the opportunity to question the contents & my therapy. By signing this form, I confirm my consent to treatment & intend this consent to cover the treatment discussed with me & such additional treatment as proposed by the therapist from time to time, to deal with my physical condition for which I sought treatment. I understand that at any time I may withdraw my consent & the treatment will be stopped.
By typing my name below, I acknowledge this document.
Should be Empty:
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