Massage Therapy Client Consent Form
Name
Email
Have you previously received a massage at our location?
Yes
No
If yes, please note any changes since last visit
*If no changes, stop here and sign bottom of form
Phone (Cell) Phone (Home)
Address with City State and Zip
Date of Birth
Are you under the age of 17?
Yes
No
If yes, a parent or guardian must be present to receive massage therapy services.
The following information will be used to help plan safe and effective massage sessions.
Please answer the questions to the best of your knowledge
Have you had a professional massage before?
Yes
No
If yes, how often do you receive massage therapy?
Do you have any difficulty lying on your front, back, or side?
Yes
No
If yes, please explain
Do you have any allergies to oils, lotions, or ointments?
Yes
No
If yes, please explain
Do you have sensitive skin?
Yes
No
Are you wearing contact lenses, dentures or a hearing aid ? wearing contact lenses, dentures or a hearing aid?
Contact Lenses
Dentures
Hearing Aid
Is there a particular area of the body where you are experiencing pain/tension?
Yes
No
If yes, please identify
Do you have any particular goals in mind for this massage session?
Yes
No
If yes, please explain
Type of massage you are requesting
Type of Massage Swedish/Relaxation Deep Tissue Hot Stones Cupping Pregnancy Massage Trigger Point
Any medical conditions your therapist should be made aware of?
Yes
No
If yes, please explain
Are you currently taking any medication?
Yes
No
If yes, please list
Please check any condition listed below that applies to you:
high blood pressure
heart conditions
recent accident or injury
spinal problems
currently pregnant
bruise easily
smoker
migranes
varicose veins
allergies
Please explain any condition that you have marked above including pregnancy due date if applicable
Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis, I must provide a physician’s written consent prior to service.
The licensee shall drape the breasts of all female clients and not engage in breast massage of female clients unless the client gives written consent before each session involving breast massage.
Draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.
If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason
**************** Therapist will enter info below ***************
Type of massage service/ technique to be used:
Signature of Massage Therapist (e sign with name)