Medical Massage

Name

First NameLast Name

Date of birth

Email

example@example.com

Address where services will be performed

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Medications

Medical History (List all medical conditions)

Surgical history

Allergies

Most recent procedure

Physician/ Surgeon name/ number

I am medically cleared by my physician/surgeon to receive medical massage therapy services performed by Nature’s Truth Therapeutic Solutions.

I understand that refunds are not available once sessions have begun, regardless of whether I complete all sessions.

LIABILITY WAIVER AND INFORMED CONSENTI understand that the medical massage therapy services provided by Nature’s Truth Therapeutic Solutions are intended for therapeutic, recovery assistance and relaxation purposes only and are not a substitute for medical examination, diagnosis, or treatment by a licensed physician.I acknowledge that I have disclosed all known medical conditions, injuries, medications, and health concerns that may affect my treatment. I understand it is my responsibility to inform the massage therapist of any discomfort, pain, or changes in my condition before, during, or after the session.I voluntarily consent to receive medical massage therapy services and understand that, although every effort is made to provide safe and professional care, there are certain inherent risks associated with massage therapy, including but not limited to soreness, bruising, muscle tenderness, aggravation of existing conditions, allergic reactions to oils or lotions, discomfort, or unforeseen physical responses.By signing below, I release and hold harmless Nature’s Truth Therapeutic Solutions, its owners, employees, contractors, and therapists from any and all liability, claims, demands, damages, injuries, losses, or causes of action arising out of or related to the massage therapy services received, except in cases of gross negligence or intentional misconduct.I understand that results are not guaranteed and that dissatisfaction with services does not constitute grounds for liability or refund unless otherwise stated in company policy.I certify that I am medically cleared by my physician and/or healthcare provider to receive medical massage therapy services when applicable.

Signature