Client Informed Consent Form

Massage Therapy




19239 Stone Oak Pkwy, Suite # 201

San Antonio, Texas 78258

Phone: 210-446-0903

Online Booking Available

Treatment Consists of:

Massage therapists treat clients by using therapeutic touch techniques to manipulate the soft-tissues of the body.

Massage therapy is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch.

I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy. I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary caregiver for any condition I may have. 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.

Client Acknowledgements: When you have any of these conditions, you may not want to book a massage.

      ·       Fever, Nausea, Vomiting, Cardio-vascular Conditions, Pacemakers, Claustrophobia

     ·       Under the influence of drugs or alcohol-including prescription pain medication

     ·       Recent operations or acute injuries Neuritis • Unstable Hypertension • Skin Diseases

Information: I understand the importance of informing my massage therapist of ALL conditions and or medications I am taking, and to let the massage therapist know about any changes to these.

Notify your therapist if you have or have ever had any of the following:

     ·  Smoker

     ·  Pregnant

     · Contagious Disease

     ·  High Blood Pressure

     ·  Allergies

     · Heart Conditions

     · Low Blood Pressure

     · Seizures

     · Epilepsy

     · Varicose Veins

     · Frequent Headaches

     · Dementia

     · Frequent Anxiety

     · Nausea

     · Skin Conditions

     · Surgeries

     Local Contraindications (Areas to be           Avoided)

     ·  Deep vein thrombosis

     ·   Aneurism

     ·   Frostbite

     ·   Local contagious or irritable skin conditions

     ·   Open sores or wounds

     · Recent surgery

     · Recent burn

     · Varicosities

     · Malignancy

Side Effects:

I understand the risks associated with massage therapy include, but are not limited to:

• Superficial bruising

• Short-term muscle soreness

• Exacerbation of undiscovered injury

I therefore release the company and the individual massage therapist from all liability concerning these injuries that may occur during the massage session.


     1.  I understand that therapeutic massage is not a substitute for traditional medical treatment or medications.

     2. I understand that the massage therapist does not diagnose illnesses or injuries, or prescribe medications.

     3. I affirm that I have stated all my known medical conditions, and answered all questions honestly.

     4. I have clearance from my physician to receive massage therapy.

     5. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly.

     6. I understand that I or the massage therapist may terminate the session at any time.


I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.


I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.


All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.





Lavender Falls Face and Body Spa

Thank you for choosing and trusting Lavender Falls Face and Body spa for your aesthetic needs.

Feel free to contact us at 210-446-0903 if you have any questions



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Signature Certificate
Document name: Massage
lock iconUnique Document ID: 780b265c8afc8e3fc9cc74afe01c9b0959d53574
Timestamp Audit
November 4, 2018 11:41 am CSTMassage Uploaded by Lavender Falls Face and Body Spa LLC. - IP