Client Information And Consultation Form Page 2
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2Your service will consist of massage to the:
(Please circle what you want to have focused on. “X” out what you want to avoid.)
SHOULDERS
LOW BACK
NECK
HANDS
FACE
MID-BACK
LEGS
ARMS
FEET
SCALP
Gluteal work will only be done over the sheet.
If you would like to have an abdominal massage, please initial here:_________
.
Abdominal work will only be provided with breast draping
***TO BE COMPLETED BY THE MASSAGE THERAPIST***
The following type(s) of massage techniques will be used in the therapy session:
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Swedish
Trigger Point
Hot Stone
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Stretching
Deep Tissue
Myofascial
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Reflexology
Reiki
Other ___________________
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Pregnancy
Sports
As the client, you are aware that draping will be used during the massage session. Breast
massage will not be conducted. Your feedback is an essential element to your treatment. Therefore, if
at any time you should be uncomfortable during the massage, you may bring it to your therapist’s
attention. You may request to end your service at any time. If the Massage Therapist feels it is
appropriate, they too may terminate the service at any time.
If you are unable to keep an appointment, you understand that 24 hours is required, otherwise,
you will be charged for the time reserved.
If, at any time, there are changes in the information given or in your condition, you will notify
your therapist, and update this form before receiving additional massages.
The massage treatment given is for the sole purpose of stress reduction, relief from muscle
tension or spasm, and to increase circulation and energy flow.
The Massage Therapist does not diagnose or prescribe for medical illness, disease, or any
other physical or mental disorder.
The Massage Therapist does not do spinal manipulations. Massage Therapy is not a substitute
for medical examination or diagnosis. It is recommended that a physician be seen for any ailment you
may have.
It is your responsibility as the client to explain and discuss all physical conditions with the
Massage Therapist so that they may do their job. Your Massage Therapist is an independent
professional and is solely responsible for your treatment.
By signing below you are verifying that you have read and fully understand this form in its
entirety.
________________________________________
_____________________________________
Client Signature
Massage Therapist Signature
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