Precision Bodywork & Therapeutics Informed Consent, Health Disclosure & Waiver

Precision Bodywork & Therapeutics

Informed Consent, Health Disclosure & Liability Waiver
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Care Provider (if applicable)
Health History Disclosure
Please check any conditions that apply. This information is
strictly confidential and is used solely to guide safe and
appropriate treatment.
Recent surgery (within 6 months)Active cancer or chemotherapyCardiovascular disease or pacemakerBlood clots / DVT historyOsteoporosis or bone fragilitySkin conditions or open woundsPregnancy (current or possible)Diabetes or circulatory disordersHyper mobility / EDSSeizure disorderNeuropathy or sensory changesImmune-compromised condition
Additional health notes, medications, or recent injuries.
Nature of services
Services provided under Precision Bodywork & Therapeutics may
include, but are not limited to:

• Deep tissue massage — sustained pressure targeting deeper muscle
layers and fascia

• Active Release Technique (ART) — movement-based soft tissue
therapy for adhesions and nerve entrapments

• Myofascial release & fascial scraping (IASTM/Graston-style) —
instrument-assisted techniques that may cause temporary bruising,
petechiae, or skin redness

• Cupping therapy — suction-based decompression; commonly leaves
circular marks lasting 3–10 days

• Trigger point therapy — localized pressure that may produce
referred pain or temporary soreness

• Stretching & assisted mobility — passive and active-assisted
range-of-motion work

• Breathwork & somatic coaching — nervous system regulation
techniques including guided breathwork

• Reiki & Energy work — non-invasive energetic support; no physical manipulation involved

• Postural & corrective exercise guidance — movement education and

exercise recommendations to support treatment outcomes
Informed consent & Acknowledgments
INHERENT RISKS:*

I understand that massage therapy and related bodywork carry inherent risks including but not limited to temporary soreness, bruising, skin marking, nerve sensitivity, dizziness, and in rare cases aggravation or pre-existing conditions. I voluntarily assume these risks.
NOT A SUBSTITUTE FOR MEDICAL CARE:*

I understand that massage therapy and somatic coaching are not substitutes for diagnosis, treatment, or advice from a licensed physician. I agree to consult a qualified healthcare provider for any medical concerns.
ACCURATE HEALTH DISCLOSURE:*

I confirmed that all health information I have provided is accurate and complete. I agree to notify the practitioner of any changes to my health status prior to each session.
RIGHT TO REFUSE / MODIFY TREATMENT:*

I understand that I may stop or modify any technique at any time during the session. It is my responsibility to communicate discomfort verbally.
CUPPING MARKS & SCRAPING RESPONSE:

I have been informed that cupping may leave circular discolorations lasting up to 10 days, and that scraping techniques (IASTM) may cause petechiae, redness, or bruising. I consent to these outcomes.
ART & DEEP TISSUE RESPONSE:*

I understand that Active Release Technique and deep tissue work can produce temporary discomfort during treatment and post-session soreness of 24-72 hours. This is a normal and expected response.
MOBILE AND OFF-SITE SESSIONS:*

For sessions conducted outside of a licensed facility, I acknowledge that the practitioner operates as an independent contractor and that the physical environment (including space, surface, and amenities) is outside the practitioner's control.
PROFESSIONAL BOUNDARIES*

I understand that massage therapy is a professional health service. Any behavior that creates an unsafe or inappropriate environment will result in immediate termination of the session without refund.
RELEASE OF LIABILITY:*

To the fullest extent permitted by California law, I release and hold harmless Whitney Robinson, DBA Precision Bodywork & Therapeutics, from any and all claims, demands, injuries, damages, or causes of action arising out of or connected with services rendered, except in cases of gross negligence or willful misconduct.
INDEMNIFICATION:*

I agree to indemnify and defend Precision Bodywork & Therapeutics against any claims arising from my failure to disclose accurate health information or my voluntary continuation of activities contraindicated by the practitioner.
CANCELLATION & PAYMENT POLICY
Cancellations made less than 24 hours before a scheduled
appointment may be subject to a late cancellation fee. No-shows
may be charged in full. Payment is due at time of service unless
otherwise arranged.
SIGNATURE & CONSENT
By signing below, I acknowledge that I have read this document
in its entirety, that I had the opportunity to ask questions, and
that I freely and voluntarily provide my informed consent to
receive services from Precision Bodywork & Therapeutics.
Signature
Printed Name

First NameLast Name
Date

MonthDayYear
Date
Session Date

MonthDayYear
Date
FOR CLIENTS UNDER 18 - PARENT / GUARDIAN AUTHORIZATION
Signature
Guardian Printed Name

First NameLast Name
Relationship to Client
Date

MonthDayYear
Date
This form is valid for one calendar year from the date of signing, or until a significant change in health status occurs, whichever comes first. A copy of this signed form will be retained in your confidential client file in compliance with California law.
Should be Empty:

Precision Bodywork & Therapeutics

Client Information

Health History Disclosure

Nature of services

Informed consent & Acknowledgments

CANCELLATION & PAYMENT POLICY

SIGNATURE & CONSENT

FOR CLIENTS UNDER 18 - PARENT / GUARDIAN AUTHORIZATION