Massage consultation and consent form

Full Name

First NameLast Name

Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Date of Birth

Date

Email

example@example.com

Your Gender

Please list any medications you are currently taking

Please tell me some more details about your allergies

Please give more information about your chronic pain

Tell me more about your orthopedic injuries including any dates

Do you have any of the following conditions

If you have indicated any conditions, please give some more details

Please tell me anything else regarding your health which might be relevant

Rate your quality of sleep

Please rate your energy levels

Rate your Stress Levels

Quality of Nutrition

Rate your exercise habits

Please tell me where

What Type of massage are you seeking?

What Pressure do you prefer?

Tell me your desired outcome from this treatment session

Please list any areas of discomfort ( Including which side of the body)

I understand that Massage Therapy 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 for any mental or physical ailment of which I am aware.

Because Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

This is a Therapeutic Massage session and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.

I understand the Massage Therapist practitioner reserves the right to refuse services to me for any reason that he deems necessary.

If I experience any pain or discomfort during the session I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.

Signature

Date