Massage Therapy Client Intake Form (Page 3 of 4) in pdf

Consent for Therapy and Waiver of Liability

The undersigned (“Client”) hereby freely consents to receipt of massage services from:

Licensed Massage Therapist’s Name

Client agrees as follows:

Client understands and agrees that they will provide the Therapist with complete and accurate health

information, and a written referral from Client’s primary healthcare provider if Client is currently receiving

care or has a specific medical condition or symptoms for which Client takes medication or receives periodic

evaluations or treatment. Client understands that massage therapy is designed to be an ancillary health aid

and is not suitable for primary medical treatment for any condition.

1. Client and Therapist have discussed the potential benefits and possible side effects of massage therapy

and have agreed upon a course of focused attention and manually therapy for the predetermined goals of

stress reduction, relief of muscular discomfort, and/or promotion of general health. Client has been

given an opportunity to ask questions of the Therapist and has received all requested information.

2. Client understands that the unclothed body will be draped at all times for warmth, sense of security, and

as a mark of massage therapy professionalism. Client agrees to immediately inform the Therapist of any

unusual sensation or discomfort so that the application of pressure may be adjusted to Client’s level of

comfort. Client understands that massage therapy is not sexual in any manner and that any illicit or

suggestive remarks or behavior on the client’s part, will result in an immediate termination of the

therapy session. Client understands that payment will be expected in full; regardless if the massage is

completed or not.

3. Client hereby assumes fully responsibility for receipt of the massage therapy, and releases and

discharges Therapist from any and all claims, liabilities, damages, actions, or causes of action arising

from the therapy received hereunder, including, without limitation, any damages arising from acts of

active or passive negligence on the part of the Therapist , to the fullest extent allowed by law.

4. Client, in signing this consent for Therapy and Waiver of Liability (“Consent”), understands and agrees

that this Consent will apply to and govern the current and all future therapy sessions performed by

Therapist

____________________________________________ _________________________________________

Client Signature

Client Printed Name

__________________

Date

____________________________________________ _________________________________________

Massage Therapist Signature

Massage Therapist Printed Name

__________________

Date

Massage Therapy Client Intake Form Page 3