Assessment First Remedial Massage Therapy Client Information And Consent Form (Page 4 of 4) in pdf

ASSESSMENT FIRST REMEDIAL MASSAGE THERAPY - Marie Trafford, RMT

INFORMED CONSENT TO MASSAGE THERAPY TREATMENT

I understand that the massage therapist is providing massage therapy services within their scope of

practice as defined by both the Massage Therapist Association of Alberta and the Massage Therapist

Association of Saskatchewan, Inc.

I hereby consent for my therapist to treat me with massage therapy for the above noted purposes

including such assessments, examinations and techniques, which may be recommended, by my

therapist.

I acknowledge that the therapist is not a physician and does not diagnose illness, disease, or any

other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a

medical examination. It is recommended that I attend my personal physician for any ailments that I

may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to

the results of the treatment. I acknowledge that with any treatment, there can be risks and those

risks have been explained to me and I assume those risks.

I acknowledge and understand that the therapist must be fully aware of my existing medical

conditions. I have completed my medical history form as provided by my therapist and disclosed to

the therapist all of those medical conditions affecting me. It is my responsibility to keep the massage

therapist updated on my medical history. The information I have provided is true and complete to the

best of my knowledge.

I authorize my therapist to release or obtain information pertaining to my condition(s) and/or

treatment to/from my other caregivers or third party payers, only when necessary and only with a

prior verbal request.

I have read the above noted consent and I have had the opportunity to question the contents and my

therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the

treatment discussed with me and such additional treatment as proposed by my therapist from time to

time, to deal with my physical condition and for which I have sought treatment. I understand that at

any time, I may withdraw my consent and treatment will be stopped.

Patient Name ____________________________________________________________

Signature of Patient/Guardian __________________________________________________________

Date Signed ____________________________________________

Assessment First Remedial Massage Therapy Client Information And Consent Form Page 4