Massage Therapy Consent Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
-
Phone Number
Address
City
County
Postcode
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
-
Phone Number
Relationship
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing? (Female only)
If yes, please specify on the field above.
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, skin conditions, cancer etc.?
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
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.
I release this massage spa The Lodge - Becky Hadlington of any responsibility in case of an accident, illness, or injury.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Submit
Should be Empty: