Massage Therapy Consent

First name

Last name

Date of Birth

Have you been hospitalized in the last 12 months?

Yes

Are you suffering from a medical condition, illness, or injury that your therapist should be aware of?

Yes

Are you allergic to anythng?

Yes

If you answered yes to any question, please elaborate

Initials

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status.

I declare that the info I’ve provided is accurate & complete