I hereby request and consent to therapeutic massage treatments on me by the Registered Massage Therapist.
I understand and am informed of the benefits of massage therapy, as well as the possible side effects, risks, and the consequences of not having such treatment. I further understand that I do not expect the Massage Therapist to be able to anticipate and explain all risks and complications, and I wish to rely on the Therapist to exercise judgment during the course of the treatment, which the Therapist feels at the time, based upon the facts then known to be in my best interest. All female patients must inform the massage therapist if they know or suspect that they are pregnant.
I have had the opportunity to ask questions and I am aware of my right to modify or stop the assessment/treatment at any time and/or refuse, alter or withdraw this consent at any time. Treatment times include assessment time; time spent getting on and off of the massage table, and remedial exercise if required. I understand that payment for services received is my responsibility and must be made at time of service. If my claim is to be submitted directly to an outside agency for payment, and for some reason the third party payer denies the claim and/or refuses to pay all or partial the full amount billed, I am responsible for paying the amount outstanding.
I am aware of the cancellation policy that requires 48 hours notice to cancel a massage appointment. Appointments that are missed will be billed a missed appointment fee (50% of full price I intend this consent to apply to all my present and future Massage Therapy visits.