Massage Therapy Consent Form
Client Information
How did you hear about us?
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
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? If so, how far along?
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
Anything else we should know?
Consent and Waiver
I, undersigned, agree with the following statements:
I authorize this massage spa clinic/center to perform the treatment or necessary procedure for my child.
I authorize the use of lotion, oil, and ointments to my body.
I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
I release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Back
Next
Your Treatment Preferences
Would you like essential oils used?
Peppermint
Lavender
Orange
Eucalyptus
No Essential Oils
Would you like massage table heated?
Yes
No
Would you like the massage table heated?
Yes
No
What level of pressure would you prefer during the massage?
Light
Medium
Firm
What type of massage experience are you looking for today?
Relaxing Massage: Focuses on gentle techniques to promote relaxation.
Therapeutic Massage: Targets specific muscle issues and tension relief.
Combination Massage: A blend of relaxing and therapeutic techniques.
Deep Tissue Massage: Focuses on deeper layers of muscle for intense relief.
Are there any areas you would like us to avoid during your massage? Please select any that apply:
Feet
Stomach
Scalp
Face
Would you like to include cupping therapy as part of your session? (Available only when booking with Megan)
Yes
No
Would you like to include cupping therapy as part of your session? (Available only when booking with Megan)
Yes
No
Would you like to incorporate stretching during your massage?
Yes
No
Would you like to incorporate stretching during your massage?
Yes
No
Would you like to upgrade your massage with CBD Massage oil for an additional $12? Benefits include: Pain Relief, Promotes calmness and reduces stress, Improved Circulation and skin Health.
Yes
No
Would you like to upgrade your massage with CBD Massage oil for $12? Benefits include: Pain Relief, Promotes calmness and reduces stress, Improved Circulation and skin Health.
Yes
No
Would you like to upgrade your massage with Magnesium Massage Oil for $12? Benefits include: Muscle recovery, sleep support and nervous system relief.
Yes
No
Would you like to upgrade your massage with Lymphatic Massage Oil for $15? This oil encourages movement and release of lymph fluids to aid in minimizing bloating, swelling, sinus congestion, and promoting a more sculpted appearance.
Yes
No
Would you like to upgrade your massage experience with Vibroacoustic therapy For an additional $10? Vibroacoustic therapy uses soothing music delivered through headphones to relax your nervous system. The massage bed also provides gentle vibrations that create a calming effect throughout your body. This unique therapy not only soothes your muscles but also "massages" your mind, allowing you to fully relax and ease into your massage session effortlessly.
Yes
No
Would you like to upgrade your massage experience with Vibroacoustic therapy For $10? Vibroacoustic therapy uses soothing music delivered through headphones to relax your nervous system. The massage bed also provides gentle vibrations that create a calming effect throughout your body. This unique therapy not only soothes your muscles but also "massages" your mind, allowing you to fully relax and ease into your massage session effortlessly.
Yes
No
Submit
Should be Empty: