Massage Therapy Client Consent Form

Name

Email

Have you previously received a massage at our location?

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?

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

1. Have you had a professional massage before?

    Yes
    No

2. If yes, how often do you receive massage therapy?

2. Do you have any difficulty lying on your front, back, or side?

    Yes
    No
    

If yes, please explain

3. Do you have any allergies to oils, lotions, or ointments?

    Yes
    No

If yes, please explain

4. Do you have sensitive skin?

    Yes
    No

5. Are you wearing contact lenses,  dentures or  a hearing aid ?  wearing contact lenses, dentures or a hearing aid?

    Contact Lenses
    Dentures
    Hearing Aid
    

6. Is there a particular area of the body where you are experiencing pain/tension?

    Yes
    No

If yes, please identify

7.  

8. Do you have any particular goals in mind for this massage session?

    Yes
    No

If yes, please explain

9. Type of massage you are requesting

Type of Massage  Swedish/RelaxationDeep TissueHot StonesCuppingPregnancy Massage   Trigger Point

10.   Any medical conditions your therapist should be made aware of?

     Yes
     No

If yes, please explain

11. Are you currently taking any medication?

     Yes
     No
     

If yes, please list

12. Please check any condition listed below that applies to you:

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)