Massage Therapy Consent Form

Massage Therapy Consent Form
Client Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
How did you hear about this practice? Referred by:*
What pronouns do you use?
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name*

First NameLast Name
Phone Number*
Relationship*
Health Data
Do you receive massages on a regular basis? If so, how often? *
Do you have any allergies? (Lotions, scents, etc)*
If yes, please specify on the field above.
Are you currently taking any medications?*
If yes, please specify on the field above.
Do you have any current injuries?*
If yes, please specify on the field above.
What kind of pressure do you prefer?*

LightFirmDeepUnsure, this is my first massage.
Do you consent to having the following areas massaged?*

Gluteal musclesPectoral musclesFeetFaceScalp
What brings you in for your appointment? What are you areas of focus?*
Are you currently pregnant or nursing?*

PregnantNursingN/A
If you are pregnant, how far along are you in your pregnancy? Please list any information I may need to know. (Example: complications, discomforts, etc)
Please indicate any conditions you currently have:*

Muscle, joint painNumbness, tinglingBruise easilyHeadachesDigestive conditionsArthritisOsteoporosis, degenerative spine/diskAllergiesDiabetesDepression,anxietyHigh,low blood pressureEpilepsy ,seizuresCancer, please specify more belowVaricose veinsBroken bonesSprains,strainsBlood clots or bleeding disordersHistory of strokesHeart diseaseDeep vein thrombosis
Other condition not listed, or more info:
If you are receiving Massage Cupping Therapy today, do you have any of the following? *Some of these are contraindicated for this modality. Others may need a Doctor’s permission prior to session, or certain areas may need to be avoided.*

Does not apply to me todayVaricose veinsDeep vein thrombosisRheumatoid arthritis flare upDiabetesLiver dysfunctionKidney dysfunctionCurrently taking blood thinnersAneurysm
Consent and Waiver
I, undersigned, agree with the following statements:*

I authorize the use of lotion, oil, and ointments to my body.I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician prior to appointment.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.
Consent For Treatment

If I experience any pain of discomfort during this session, I will immediately inform the practitioner so that pressure may be adjusted to my comfort level. Massage draping is required during all sessions. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness. Because my massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all known medical conditions and answered questions honestly. I agree to update the practitioner of any changes in my medical profile and understand that there is no liability on the practitioners fault if I fail to do so. Understanding all of this, I give my consent to receive care.
Signature of the Client*

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Date Signed*

MonthDayYear
Date
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Massage Therapy Consent Form

Client Information

Emergency Contact Details

Health Data

Consent and Waiver