Massage & Wellness Intake Form (Page 2 of 2) in pdf

INFORMED CONSENT TO MASSAGE THERAPY TREATMENT

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 or 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 perso nal 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 informatio n pertaining to my condition(s) and/or treatment

to/from my other caregivers or third party payers.

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.

Client Name

________________________ Signature of Client/Guardian ________________________

Date Signed ______________________________________

Massage & Wellness Intake Form Page 2