Seated Massage Client Information And Release Form printable pdf download

Seated Massage Client Information And Release Form

Seated Massage Client Information and Release Form

Thank you for your interest in massage therapy. Please fill out the information below and

give your completed form to the massage practitioner

Name:____________________________________________

Birth date:____________

Are you currently suffering from any ailment that could be affected by today’s chair massage?

Yes No

If yes, please explain:

______________________________________________________________________________

___________________________

If yes, are you currently under a doctor’s supervision for this ailment? Yes No

Please read the following statement, then sign and date below to indicate that you have

read and understand the statement.

The therapist whose signature appears below is not responsible for the aggravation of

conditions that were present, but not disclosed, at the time of the massage and which may

be affected by the massage.

Print Name: ______________________________________

Date: _____________

Signature:________________________________________

FOR MASSAGE THERAPIST USE ONLY:

Client’s Name: ___________________________________ PEC Yes No

Comments:

Therapist signature: ________________________________ Date: ________________

Seated Massage Client Information And Release Form