Massage Consent Form

1. Emergency Contact: *
2. Emergency Contact Relationship: *
3. Emergency Contact Phone: *
Medical Information
4. Are you taking any medications? *
5. If yes, please list name and use:
6. Do you have any allergies? *
7. If yes, please list name and use:
8. Are you currently pregnant? *
9. If yes, how far along:
10. Any high risk factors?
11. Do you suffer from chronic pain? *
12. If yes, please explain:
13. What makes it better?
14. What makes it worse?
15. Have you had any injuries or surgeries? *
16. If yes, please list what was done and approximate date of injury or surgery:
17. Please indicate any of the following that apply to you:
18. Explain any conditions you have marked above:
19. Are there any other conditions that not listed above?
20. Have you had a professional massage before?
21. What pressure do you prefer? *
22. Do you have any allergies or sensitivities? *
23. If yes, please explain:
24. What are you goals for this treatment session?
I understand that the massage/body work 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 comfort level. I further understand that massage/body work should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/body work therapist 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 should be constructed as such. Because massage/body work 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 therapist updated as to any changes in my medical profile and understand there should be no liability on the therapists part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of thee scheduled appointment.
By signing below, I agree that all the information above is true. *