I understand that by signing this form I am choosing to proceed with the treatment and/or treatment plan proposed at this time. I understand that I may change my mind, alter or refuse treatment at any time during this or any other treatment. This completed form will be kept in my client file held by Ace Sports Clinic.
Please read and sign on the following screen:
I have been informed of and have understood the reason(s) for receiving massage to my breast tissue.
Regarding massage of my breast(s), I have been informed of the clinical indicators for breast massage that relate to my situation as per Massage Therapy Standards of Practice.
I understand that the nipples and/or areolas of my breasts will not be touched during the breast massage.
I have been informed of and have understood the reason(s) for receiving massage to my:
• Chest wall muscles
• Inner thigh(s)
• Buttock(s) (gluteal muscles)
For any of the above areas, I have been informed of the reasons, the benefits, risks and side effects, and the proposed draping (covering). In addition, I have had all of my questions regarding this treatment answered by my Massage Therapist.
I understand that I can alter or rescind my consent at any time during this or any treatment.
At this time, I am voluntarily giving my consent for the treatment and/or treatment plan.