Client Information And Consultation Form - Siena Massage (Page 2 of 2) in pdf

In compliance with Title 25, Texas Administrative Code §140.304, clients are required to complete

the following release prior to the massage session:

FEEDBACK: I understand that my feedback is an essential element in my treatment, therefore if at any time I

should become uncomfortable during the massage I will bring it to my therapist’s attention immediately and/or

request that the session end.

Please Initial: ______

PECTORAL/ADDUCTOR/GLUTEAL MASSAGE: Your therapist will provide massage therapy based on your

personal preferences and needs. However, our therapists will not massage certain muscle groups unless you

provide written approval prior to the session:

I hereby give consent for my massage therapist to implement pectoral, adductor and/or gluteal massage in my

therapy sessions.

Please circle:

Yes

DRAPING: For your privacy and comfort, Siena Massage policy requires therapists to use draping with

Please Initial: ______

sheets/blankets at all times during every massage session.

CLIENT STATEMENTS AND UNDERSTANDINGS:

I am not aware of any medical condition or specific symptoms that may be a contraindication for massage therapy. In

cases where one or more medical conditions exist, I understand that a referral from my primary care provider is required

prior to service, and that the massage I receive is provided for the purpose of relaxation, relief of muscular tension and/or

improved circulation. If I experience any pain or discomfort during any session I will immediately inform the practitioner

so the technique may be adjusted to my level of comfort. I further understand that massage should not be construed as a

substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other

qualified medical specialist if any mental or physical ailments exist. I understand that massage practitioners are not

qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that

nothing said in the course of any massage session should be construed as medical advice. I affirm that I have stated all

my known medical conditions and answered all questions honestly. I agree to keep Siena Massage updated regarding

any changes in my medical profile and understand that Siena Massage shall not be liable should I fail to do so.

I understand that any illicit, sexually suggestive remarks, inappropriate behavior or advances made by me will result in

immediate termination of the session and I will be responsible for full payment of the scheduled appointment. Siena

Massage reserves the right to refuse service to any client at any time for any reason at Siena Massage’s sole discretion.

We request that any cancellations occur at least 6 hours in advance, otherwise we reserve the right to charge full price

for the appointment.

I have read, understand and agree to be bound by the information, terms and conditions listed above.

Client Signature: ____________________________________________________ Date: _________________

Client Printed Name: ___________________________________________________

LIC # ME1459

Client Information And Consultation Form - Siena Massage Page 2