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 / Province

Postal / Zip Code Country
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 {fullName3} understand that by purchasing a massage session from themassagenegotiator.com's network of massage therapists, I am allowing said massage therapist to work on my body for the purchased amount of time in one of the modalities he or she is trained, educated, licensed, and insured to perform said modality service on my body. I hold any massage therapist networking through themassagenegotiator.com free from liability for any injury that I may have due to a pre-existing condition or not having my doctor approve massage therapy on any condition not disclosed at or before the initialization of my massage session. 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. Any pre-existing health conditions are to be disclosed before the massage session begins and I know that I am using massage as an alternative therapy to treat pain possibly caused by the soft tissue of my muscles, tendons, or ligaments of my body and do not expect to be cured from pain radiating from underlying ailments that are supervised by one of my physicians. Although, in many cases pain is managed effectively by massage therapy.

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. Any illicit requests to the massage therapist at any time suggested or implied is reason enough to automatically end the massage therapy appointment with zero refund and possibly have law enforcement called if needed.

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. Specifying only having one area of your body worked the entire massage session limits the effects that massage can produce in relieving pain and it is counterintuitive to the benefits massage can provide with a holistic approach to healing your body, mind, and spirit.

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. I understand my massage therapist might not be able to intuitively know when I want more pressure when my muscles spasm or contract with more or less pressure as some clients want less pressure to reduce pain and others want to endure it to fix underlying muscle aches.

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. Or more pillows, side lying, prone, supine, etc. If I request deeper tissue on areas my muscles tighten up when deeper tissue massage applied and body doesn't relax, I understand that I could feel worse the next couple of days and have less movement then before the massage as muscle fibers were put through mild trauma to remove underlying tension in the muscles. If I do not want deeper massage on me after scheduling it, then I only have to tell my massage therapist not to massage as deep in those areas or only on one area, i.e. upper back.

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 will not have guests in or around the vicinity of my massage therapist while my massage therapy session is involved making my massage therapist feel uncomfortable, unsafe, or interfering with my massage benefits by asking questions or making comments on service. Unless, I am under the care of a mental health professional and need to have the mental health professional near me to handle any instances I might put my massage therapist in danger or undergo a mental psychosis that makes my massage therapist feel uncomfortable. If the latter does occur, the massage session is to be terminated and no costs refunded, due to the opportunity cost of having delivered said service and losing income on this scheduled appointment. Regardless, if the full time of service is completed or not. If an emergency response team is needed for me during or after the session, I will not be refunded the mobile massage service fee. This is due to the time spent by outside contractors and many trauma patients that use massage as an alternative to treat their pain or manage it and find their pain is more psychological. Also, any areas having skin rashes or abrasians cannot be massaged.

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 any of the network of massage therapists using themassagenegotiator.com is state licensed, educated, and trained to perform from school, franchise training, or continuing education more than a few or all of the following: 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, hemp massage therapy, aromatherapy, sports pain relief gel/balm/lotion massage, sports variable speed tension relief massage, oncology massage, elderly massage, disabled massage, and trigger point therapy massage.

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 light pressure could be 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 these terms and conditions *

Yes
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

Please Sign and Date this form confirming you agree to the above statements. *

Clear
Date *

Month Day Year
Date
Thank you for filling out your liability and consent to have massage therapy services by The Massage Negotiator. You can submit the form now and a copy will be emailed to you at the email address you provided above now. You can also fill out the rest of the form to customize your first massage session.
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) Which areas do you want FOCUSED?

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
Thank you for taking time from your busy life to fill out this form. Have a wonderful day and I look forward to accomplishing your massage goals with you in the future.
If this form does not submit when you turn it in, please print it out and fill it out, then email it to janis@themassagenegotiator.com. Some fields are also required and it won't send unless they are filled in or your age is greater than 18 years of age. Thank you.
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The Massage Negotiator Client Liability Form :