Zobeautiful BEAUTY- Hot Stone Massage Release Form

Hot Stone Massage Release Form

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Hot Stone Massage Contraindications

Hot stone massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions.

You must inform your massage therapist/practitioner if you have any of the following conditions which may make hot stone massage contraindcated or may require your therapist/practitioner to alter the massage.
Conditions with associated risks:
Client's Release
I First Name * Last Name * , have read and understand the aforementioned conditions which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed any and all health risk factors.
Please specify which condition(s) apply to you?*

PregnancyBlood clot(s)DiabetesNeuropathyInflammatory skin conditionsAutoimmune condition (MS, Lupus, RA, etc.)Open wounds or soresPeripheral vascular diseaseHypotension or HypertensionHeat sensitivityCancer (with or without treatment)Compromised immune systemVaricose veinsEdema or LymphedemaUnder the influence of drugs or alcoholCardiovascular disease
Please check the following that applies to you*

I Understand the information contained on this form and confirm that I do not have any of the above conditions.I do have one or more of the conditions listed above and therefore make(s) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.
I understand that I will be receiving hot stone massage as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during my treatment(s).
Signature*

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Date*

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