SLJSpaGirl - Massage Consent Form
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Massage Consent Form

Massage Consent Form


Please fill out ALL personal info as some people have the same name.


We want to be sure the health info is connected to the correct profile.

Massage Consent Form
Name
Phone
Address (include city & state please)
Email Address (required to submit form)
Birthdate
Occupation
Where do you feel discomfort most often?
How would you classify your stress level?
Have you ever had massage therapy?
Check all that apply: Please check NONE if none apply
Do you Smoke?
Are you currently taking any medications or herbal treatments?
Please list any Surgeries or Injuries that occurred within the last 5 years.
May I contact your physician if the need should arise?
Physician Name
“I certify that the above information is accurate as it concerns my safety for massage therapy and the safety of the therapist. I do not hold the therapist responsible for injuries from conditions I did not disclose. I further understand that this treatment is not sexual in any nature and that the session may be terminated with fee due for services rendered if inappropriate behavior is displayed. A drape will be required at all times and if uncomfortable for any reason I may terminate the session. “
“THE THERAPIST SHALL NOT ENGAGE IN BREAST MASSAGE OF FEMALE CLIENT WITHOUT THE WRITTEN CONSENT OF THE CLIENT”
I give consent for massage therapy