INFORMED CONSENT
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I understand that the massage services are intended to promote relaxation and circulation and to relieve stress, muscle tension, spasms, and related pain. I understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician other qualified medical specialist for any physical ailment that I am aware of. I further understand that massage therapists are not qualified to perform adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session should be construed as such.
I understand that my therapist cannot guarantee exactly how my body will respond to any treatment.
If I experience any pain or discomfort during massage sessions, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.
I understand that any illicit or sexually suggestive remarks or advances will result in immediate termination of the session and that I will nonetheless be responsible to pay for the whole time scheduled. Police may be summoned and charges pressed.
I understand that the therapist reserves the right to refuse to perform massage on anyone whom she deems to have a condition for which massage is contraindicated. This includes a communicable disease, a fever, and the recent use of alcohol or recreational drugs.
If I have a cold or feel like I’m getting sick, I will cancel the session in as timely a manner as possible.
I understand that all information and anything said in my session will be kept confidential, although I also understand that, as medical providers, massage therapists are required by law to report any evidence of abuse of those under others’ care. Adults who are free to leave abusive situations will receive utmost confidentiality and care.
I understand that I have the right to know and should ask about any treatments I am receiving. I may withdraw my consent at any time and treatment will be stopped or modified with my consent.
By signing this form, I consent to being treated with massage therapy, including such assessments, examinations and techniques that may be recommended by my therapist.
I have read this consent form and have had the opportunity to question its contents.
Client Name(Printed)__________________________________________________________
Client Signature _____________________________________________________________
LMT signature___________________________________ Date Signed:____________________
I understand that my therapist cannot guarantee exactly how my body will respond to any treatment.
If I experience any pain or discomfort during massage sessions, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.
I understand that any illicit or sexually suggestive remarks or advances will result in immediate termination of the session and that I will nonetheless be responsible to pay for the whole time scheduled. Police may be summoned and charges pressed.
I understand that the therapist reserves the right to refuse to perform massage on anyone whom she deems to have a condition for which massage is contraindicated. This includes a communicable disease, a fever, and the recent use of alcohol or recreational drugs.
If I have a cold or feel like I’m getting sick, I will cancel the session in as timely a manner as possible.
I understand that all information and anything said in my session will be kept confidential, although I also understand that, as medical providers, massage therapists are required by law to report any evidence of abuse of those under others’ care. Adults who are free to leave abusive situations will receive utmost confidentiality and care.
I understand that I have the right to know and should ask about any treatments I am receiving. I may withdraw my consent at any time and treatment will be stopped or modified with my consent.
By signing this form, I consent to being treated with massage therapy, including such assessments, examinations and techniques that may be recommended by my therapist.
I have read this consent form and have had the opportunity to question its contents.
Client Name(Printed)__________________________________________________________
Client Signature _____________________________________________________________
LMT signature___________________________________ Date Signed:____________________