Massage Therapy Consent Form
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1Massage Therapy Consent
Form
THIS FORM MUST BE COMPLETED & SIGNED BEFORE
.
RECEIVING A MASSAGE
General Information
Emergency Contact Information
Date:__________________________________
Name:_________________________
Name:_________________________________
Relation to you:__________________
Address:_______________________________
Phone Number:__________________
Phone Number:__________________________
Email Address: __________________________
Have you ever experienced a professional massage? ____ YES ____ NO
Which areas would you like to focus on during this massage? __________________________________
Do you have any of the following conditions? If yes, please explain below as clearly as possible:
_____ Stress
_____ Cardiac/circulatory
_____ Epilepsy or seizures
_____ Allergies
problems
_____ Bruise easily
_____ Contagious disease
_____ Arthritis
_____ Joint swelling
_____ Diabetes
_____ Sensitive to touch or
_____ Varicose veins
_____ Wear contact lenses
pressure
_____ Depression
_____ Back pain
_____ Frequent headaches
_____ Numbness or stabbing
_____ Pregnant
_____ Osteoporosis
pains? Explain below
_____ Cancer
_____ High blood pressure? If yes, are you taking medication for this? Explain below.
_____________________________________________________________________________
_____ Surgery in the past five years? Explain below.
_____________________________________________________________________________
_____ Accident or suffered any injuries in the past 2 years? Broken bones, etc. Explain below.
_____________________________________________________________________________
_____ Other medical conditions not listed. Explain below.
Comments:___________________________________________________________________
I understand that the massage I receive is provided for the basic purpose of relaxation and relief of
muscular tension. 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. I further understand
that massage should not be construed as a substitute for medical examination, diagnosis, or treatment. I
understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose,
prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given
should be construed as such. 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 massage therapist updated as to any changes in my medical profile during
the session and understand that there shall be no liability on the massage therapists part should I fail to
do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in
immediate termination of the session. I also understand that the Massage Therapist reserves the right to
refuse to perform massage on anyone whom he/she deems to have a condition for which massage is
contraindicated.
Client Signature ____________________
Therapist Initials __________________
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