Massage Consent Form

Massage Consent Form
Date of Appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
In case of emergency contact (Name & Number)
How did you hear about us?
If friend /client referral, please list name so they can get reward points
Age
Gender / Pronoun
What is your major concern or focus today?
Are you pregnant?
If yes, how many weeks?
List any allergies:
List any medications currently being used:
List any pre-existing medical conditions, surgeries you've had and year performed:
To the best of my knowledge, I have answered the above questions honestly.
Type name here

I understand the goals and limitations of massage and realize that a massage serves as no substitution for a medical examination, diagnosis, or treatment.

Prior to receiving treatment, I have been candid in revealing any condition, medications, allergies or sensitivities, product usage, and any other pertinent information that may have impact on my treatment.

I understand, and I am informed that, as in all health care, there are some risks to treatment, which, if applicable, will be discussed before the treatment.

Because massage should not be performed under certain medical conditions, I attest that I have revealed all known medical conditions and answered all questions honestly.

I understand that any illicit or sexually suggestive remarks or advances made by me or the use of my cell phone to take any pictures while in the massage session will result in immediate termination of the session and thus, terminating my rights to remain a client of Dolce Organic Salon, Med Spa & Salt Room.

I understand that therapists at Dolce Organic Salon, Med Spa & Salt Room reserve the right to refuse to perform treatment on any client for any reason.

I understand that there are certain risks to woman who are pregnant or trying to get pregnant.
By signing below, I acknowledge that I have read and understood the above Informed Consent. I have taken the opportunity to address any questions I have regarding this Consent with a staff member of Dolce Organic Salon, Med Spa & Salt Room and my questions have been answered to my satisfaction. I have been adequately informed and wish to proceed with my treatment. As a client of Dolce Organic Salon, Med Spa & Salt Room. I hold harmless Kazar Business Ventures for any events under the care of any Dolce Organic Salon, Med Spa & Salt Room employee.
Client Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: