New Massage Client Liability Consent Form

The Massage Negotiator Client Liability Form :

Required by law to massage over the age of 18 (or with separate consent form for massage of a minor), keep progressive reports of clients, protect this information by HIPPA/HIPAA regulations, maintain these client details to prevent massage and bodywork contraindications. An assessment that fully details the modalities and services provided for that session, the appointment date, time of appointment, suggestions for maintaining health and wellness and for your next massage appointment are filled in by your massage therapist and emailed to you after every appointment in 0-7 days (not required by law). You must fill in a new form every 1-2 years for any unforeseen health conditions or limitations you might need to change for your subsequent massage sessions. All massage sessions are customizable and accommodating to any new changes you might experience. After filling out this form you will receive a copy at the email you provided for your records.
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Date
Please provide your service address if this is for mobile massage therapy services. *

Street Address

Street Address Line 2

City State

Zip Code
If you have a gated or private entrance requiring a pin code or special instructions, please enter it now.
pin code to private entrance of massage service address
Phone Number *

Area Code Phone Number
Please enter your e-mail so that your Suggestive/Objective/Assessment/Plan (SOAP) notes on your massage session can be emailed to you with your receipt within a few days after your appointment. *

Confirmation Email
Please read the following terms and conditions and sign your name after reading each item below about your massage session.
I understand that by purchasing a massage session from Janis Corona, LMT #18843, I am allowing said massage therapist to work on my body for the purchased amount of time in one of the modalities she is trained, educated, licensed, and insured to perform said modality service on my body. All laws and precautions common to the modality and my health condition as indicated below will be followed according to the state of California and the California Massage Therapy Council standards and practices for massage therapists operating in California.

Only massage of those body parts uncovered and not including the genitalia, breasts, or the medial gluteal region along the sacrum (buttocks crack) will be performed. The abdomen will only be massaged if requested before the session for digestive or scar adhesion myofascial and/or lymph drainage methods, and the breasts will be covered for females as well as underwear will be worn by both genders. Draping protocols will be followed for heat sensitive patrons and only each body part worked on will be undraped and re-draped by linens when moving to the next body part, until the conclusion of the massage session.

Prone (face down), supine (face up), and/or side lying massage positions will be used in the session, according to your pre-determined assessment and consultation.

If I find other areas that are in pain, ache, tender, and/or need more or less time or pressure focusing on that area as it is encountered, I will notify the massage therapist at that time so that my massage session maximizes my expectations for this service and holds me free from complaining about my massage therapist not being able to intuitively know I want more pressure when my muscles spasm or contract with more or less pressure.

I understand each client is unique in their associated pain, sensitivity, and patterns of aches and tension and do not expect my massage therapist to know exactly how I want these conditions addressed without me verbally explaining that I want more pressure, less pressure, some stretching, some heat, some cold, and so on applied to that area of my body.

Any conversation or body language that can be understood to be sexually explicit or implied towards my massage therapist, violent towards my massage therapist, offensive towards my massage therapist, or socially and reasonably considered disrespectful towards my massage therapist is reason enough to have my massage session end and pay for the service will not be refunded.

I understand that having a location with cell phone service and freedom to enjoy my massage in a peaceful environment I have arranged at my personal location is necessary to maximize the benefits from my massage session and will not schedule my massage session in an area without cell phone service, with people or pets that harass my massage therapist, and that this is reason to lose my deposit on the massage session if these requests are not honored.

I understand that it is important to block from my schedule the right amount of time for each scheduled session and to be prompt in starting the massage session and ending the session so that the full amount of hands-on time for the massage is completed.

The massage modalities that Janis Corona, LMT #18843 is licensed, educated, and trained to perform from school, franchise training, or continuing education are: Swedish, Swedish deep-tissue massage, Shiatsu massage, Sports massage, Lymphatic drainage massage, cranio-sacral massage, prenatal massage, myofascial massage, stretching, cupping, instrument assisted soft tissue mobilization tools (IASTM), kinesiology taping, hot stone therapy, cold stone therapy, aromatherapy, and trigger point therapy.

I understand that light pressure, medium pressure, and deep pressure and firm pressure vary between massage therapists. Firm pressure is a more spread out pressure across more of the major muscles of my body, where as light pressure could be the similar but with less pressure applied. Deep massage is to reach the deeper adhesions between deeper layers of muscle and can be applied with smaller points like the thumbs and elbows, or with a very strong flat surface of the hand and forearm by the massage therapist. I will indicate during the massage if the pressure needs to be increased or reduced by my massage therapist and if I want a broader surface (palms and forearms) or smaller surface of application (knuckles, elbows, and fingers).
Do you agree to the above terms and descriptions described for mobile massage therapy services at your service address? *

Yes
Please sign agreeing to terms and conditions for mobile massage services below with your signature. *

Clear
Please enter in today's date for agreement of terms and conditions described above for mobile massage therapy services. *

Month Day Year
Date
Do you prefer a female or male massage therapist or no preference?

female massage therapist male massage therapist No preference undecided
Do you prefer lotion or oil?

lotion oil lotion or oil, no preference
Please briefly describe the reason you want a mobile massage therapy session, what areas you want massaged, the pressure you want, what techniques you want, any health conditions you have, when your last massage was, if this massage is for somebody else or you, and anything else you feel you want your massage therapist to know before your massage appointment.
Please select the following health conditions you have

High or Low Blood Pressure Diabetes Kidney disease Cancer Spinal injuries amputated limb missing organ (i.e. left lung, kidney) recent abdominal surgery (post natal, tummy tuck, hysterectomy, etc.) Rheumatoid Arthritis Osteoporosis Leukemia Use Blood Thinners Migraines Recent Surgeries (limbs, neck, low back, shoulders, etc.) Skin Abrasions Bruise easily Plantar Fasciitis Fibromyalgia Ticklish feet or other areas of body Cold hands and feet Irritable Bowel Syndrom (IBS)

If you are getting a massage for pain relief or management, rate your pain on a scale of 1 to 10, with 1 being the least pain ever felt by you and 10 being the most amount of pain

	1	2	3	4	5	6	7	8	9	10

1 is Least , 10 is Most

Rate your sleep cycle each week as 1 being the least amount of sleep and 10 being the most amount of sleep you could want in one week.

	1	2	3	4	5	6	7	8	9	10

1 is Least, 10 is Most

Rate how stressed you are during the week with changes that have happened in your life that you are still adjusting to are repairing, with 1 being no stress at all and 10 being the most stress you have ever experienced in your life.

	1	2	3	4	5	6	7	8	9	10

1 is No Stress, 10 is Most Stressed Ever

Thank you for filling out your liability and consent to have massage therapy services by The Massage Negotiator. You can save the form now and email janis@themassagenegotiator.com a copy or continue filling out the optional customization of your first massage session on this form. You can also submit it as is if all required fields are filled in by clicking submit below.
Customization of Massage Session for First Time Clients
(Optional) Select the TYPE OF PRESSURE you want used most of your massage session. Given an area of your body like your back, the deep layers of your back are your erector spinae muscles along the spine and intercostal muscles of the ribs, the middle layers are your rhomboids between the shoulders of upper back, and the top or superficial layer is the trapezius of the upper and mid back and the lattisimus of the mid back. These muscles have fascia around them that can make them tight and densely packed together with adhesions or knots between and in the muscle layers and fascia. Select which pressure you want based on how deep or superficial you want your massage pressure to be. Relaxing pressure is relative to your preference. Some people relax with deeper pressure and others think it painful, while some relax with lighter pressure and others could think its unsettling.

Light (only superficial muscles reached) medium (just reaching middle level muscles, not too painful) firm (broader pressure) deep tissue (deep layer muscles) super deep tissue (very dense muscle layers need more pressure)
(Optional) Which type of massage modalities are you comfortable with being performed during your massage session?

Swedish (speed and pressure of application vary and don't have to be fixed, such as deep tissue with strong application and slowly to the back AND limbs) Variable Speed Sports Massage Tool (good for precise tendon and muscle adhesion pressure and percussion, or as the larger, flat, broad application with longer movements towards the heart for lymphatic drainage) Accupressure (deep tissue massage with thumbs or elbows along long muscles of body and the deeper muscle layers of body) Sports (stretching involved, can vary in speed of massage from slow and elongated strokes of fibers in muscle or fast to stimulate circulation and prepare body for events) Stretches (not the entire session, but for region specific areas such as to increase range of motion around the hips, neck, knees, elbows, and ankles) Lymphatic drainage (skin rolling and light rhythmic strokes to eliminate edema) Myofascial release (tight, rough, and painful, without oils or lotions, done before other modalities, can be done with Chinese cupping as less painful way of using cross-frictional muscle massage to break apart adhesions in connective tissue and between muscle fibers) Reflexology of hands and feet (this is relaxing and great for people who cannot withstand a moderate amount of pressure during massage, this is also good for calming the nervous system, but not recommended if you have feet that get uncomfortably ticklish) Pre-natal not high-risk (high risk is: less than 3 months pregnant, older than 35 years, previous miscarriages, high blood pressure, gestational diabetes, ovarian or uterine cysts or tumors, endometriosis, obese, anorexic, and other conditions your doctor has diagnosed as 'high-risk' pregnancy) Pre-natal (high-risk, you have a doctor's note, the pressure will be medium at most, the neck, ankles, and thumbs avoided) Chinese Cupping (as long as you don't have cardiac disease, DVT or PE, anemia, blood thinner use, leukemia, diabetes, cancer, osteoporosis, hematomas, or skin abrasions you can have Chinese cupping done for breaking apart adhesions, increasing circulation and healing , relieving inflammation, for fibromyalgia treatment, for lymph drainage, and myofascial massage) Full spectrum CBD (.oo3 THC) TOPICAL (must be 18 or older)
(Optional) Which areas do you want AVOIDED?

hair face feet glutial muscles lower back upper arms forearms elbows calves hamstrings (back of legs) quadriceps (front thighs) hands neck knees pectoralis major (chest) abdomen (digestion/lymph drainage)
(Optional) Select what tools of your massage therapists you want used the most when massaging you, in other words what STYLE of massage do you want? Visit https://themassagenegotiator.com/modalities to read up on some of these items.

thumbs (common) knuckles (also common if MT has long nails) fists ( for gathering tissue layers and rolling out the adhesions in the layers) Variable Speed Sports Massage Tool palms of hands (for firm, light, and medium pressure) feet (for accupressure of large muscle areas like upper back, thighs, hamstrings, and hips) elbows (for deeper pressure) forearms (for deeper medium pressure, but not deep pressure unless the sides of body like the Tendons of the legs) Hot Stones Cold Stones Chinese Cups Integrative Assisted Soft Tissue Mobilization (IASTM) tools Full Spectrum CBD oil Open to trying anything that works sound therapy
(Optional) What are your massage goals? In other words, what do you expect to accomplish during your massage session?

increased range of motion relaxed state of mind less to no pain in areas of my body that ache less fluid build up in areas of my body that have edema less pain related to fibromyalgia less inflammation from stress Sleep better less tension less anxiety
(Optional) Which additional services would you like to add to your massage session?

aromatherapy hot stone massage cold stone massage variable speed massage for lymph drainage variable speed massage for sports massage localized pain relief instrument assisted soft tissue (IASTM) tool, stainless steel or gua sha tool gua sha rose quarts tools for face massage and aiding in draining lymph from face CBD oil/balm for immunity boost and pain relief kinesiology taping with sports balm/gel for pain relief Dynamic cupping for lymph drainage, myofascial massage, and/or promoting immunity and recovery
(Optional) How did you hear about us?
(Optional) Will you be willing to recommend us?

Yes Maybe No
(Optional) Will you allow themassagenegotiator.com to contact you about promotional deals, send you your assessment and receipt to your email, text you, or call you about promotional offers? Select all that apply.

email promotional deals text me promotional offers call me about promotional offers send me my assessment and suggestions for next massage service and detailed receipt
If your friend referred you to themassagenegotiator.com for massage therapy services, who is your friend?
Client's Friend's name
Should be Empty:

The Massage Negotiator Client Liability Form :