• MASSAGE THERAPY CONSENT FORM

  • If you are under 18 please have your parent/guardian complete this form.

  • ADULT WAIVER

    Massage Facility: Ethos Wellness & Recovery

    Massage Therapist: Elizabeth Griffin, LMT

    By signing below, I agree to the following:

    1. I voluntarily request and consent to receiving massage therapy.


    2. I understand that the massage service offered is for the purposes of general wellness, stress reduction, and relief of muscular tension only.


    3. I do not have any injuries or conditions that prevent me from receiving massage therapy. I understand the importance of informing my massage therapist of all medical conditions and medications that I am taking, and that there may be additional risks based on my physical condition.


    4. If I experience any pain or discomfort, I will immediately inform my therapist so that the pressure or techniques used can be adjusted to my comfort level. I will not hold my massage therapist responsible for any pain or discomfort I experience during or after the session.


    5. I understand the risks associated with massage therapy include, but are not limited to:
    Superficial bruising.
    Short-term muscle soreness.
    Exacerbation of undiscovered injury.


    6. I do not have any contagious conditions that may put my massage therapist or other clients at risk.


    7. I understand that I or the massage therapist may terminate the session at any time.


    8. I have been given the opportunity to ask questions about massage therapy and my questions have been answered.


    I have been advised of the policies and procedures pertaining to massage and I understand these policies. Information regarding massage in general, benefits, contraindications of massage, and possible alternative therapies have been explained to me. I further understand that massage therapy is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the massage should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.

    By signing this form, I give my consent to proceed with the massage service as outlined above.

  • CHILD WAIVER

    Massage Facility: Ethos Wellness & Recovery

    Massage Therapist: Elizabeth Griffin, LMT

     

    By signing below, you agree that you are the parent or legal guardian of the minor receiving treatments at Ethos Wellness & Recovery. You understand that you are required to remain at the facility for the entirety of the minor’s treatments. We may also request that you remain in the treatment room to supervise all interactions between the therapist and the minor. You also agree that you have informed the therapist of all medical diagnoses, symptoms, medications, and complaints associated with the minor receiving treatments.


    Guidelines:

    • Minors (all clients under the age of 18- unless otherwise emancipated) can only receive massage with written parental/legal guardian consent. For clients age 14 and under, the parent/guardian is recommended to be present in the treatment room.

    • Both client and parent/guardian are comfortable with the minor being in the treatment room by themselves; otherwise parent/guardian should be in the treatment room during each session.

    • Appropriate draping will be used at all times during the massage, only areas being massaged are uncovered.


    I {name} certify that I am parent or legal guardian of {parentName} who is {childsAge} years of age as of today. I have completed the Intake Form for the above-mentioned minor and informed the therapist of all relevant medical history and concerns. I understand the scope of massage therapy and that it is not meant to diagnose, treat, or cure any conditions and is not a replacement for standard medical care. I give permission for my minor child to receive treatment(s) at this facility and agree to all the above terms.

     

  • INITIAL HERE if both client and parent/guardian are comfortable with the minor being in the treatment room by themselves; otherwise parent/guardian should be in the treatment room during each session.

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