Consent for Massage

Massage Client Waiver

Please take a moment to read and initial all of the following statements:

 

If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.                           

 

Initial Here I understand that the services offered today are not a substitute for medical care.  I understand that my therapist is not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat physical or mental illness.                                                

 

Initial Here I affirm that I have notified my therapist of all known medical conditions and injuries.        

 

Initial Here I agree to inform the therapist of any changes in my health and medical condition.  I understand that there shall be no liability on the therapist’s part should I forget to do so.

Initial Here I understand that massage is entirely therapeutic and non-sexual in nature.                      

 

Initial Here By signing this release, I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.

 

Initial Here I understand that should I cancel an appointment less than 24 hours before the scheduled time or “no show” an appointment, I am subject to a fee equal to the cost of the missed appointment.  If the appointment was booked under a gift certificate, it will be voided in lieu of the fee.

Initial Here

 

I have received the policy statement, and have read and agree to the policies therein.


Signee Information

Cell

Work

Name

Phone







(We send discounts for referrals!)

Massage History/Treatment Information







(i.e, relaxation, pain relief, reduce stress…)



























Health History:






































Sign Here

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.