Forms
Please review the forms below prior to your appointment.
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Client Consent Form
This record of consent is required before the first assessment or treatment and will be maintained confidentially in the client file. Massage Therapy includes the assessment and treatment of the soft tissues and joints of the body, using soft tissue manipulation, joint mobilization, hydrotherapy, remedial exercises and self-care programs as determined by the therapist. Treatment plans will be discussed in advanced with the client and must be agreed upon prior to start.
By signing this form, the client agrees to the following;
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All massage treatments, information and records will be kept confidential and securely stored for use only by my massage therapist.
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Written consent must be given by me prior to any disclosure or sharing of my personal and clinical information with any third party.
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Privacy will be assured as I have the right to undress only to my comfort level and according to the requirements of the treatment.
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Draping will be used by the therapist as required to expose only those parts of my body that require treatment and/or as I choose to ensure my comfort during treatment.
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During treatment, the therapist will endeavor to work such that a pain level of 6 - 7 is not exceeded, based on a pain scale of 1 - 10.
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If at any time during the treatment, I feel uncomfortable with the treatment for any reason, I have the right to request an immediate stop to the session or request modifications to the treatment, regardless of prior consent given.
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Promptness is expected for all appointments. In the event of lateness, the massage may be cut short due to other commitments of the therapist.
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I give my permission to receive massage services.
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I acknowledge that massage therapy is not a substitute for medical care, medical examination and diagnosis.
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I understand that the service provider does not diagnose illnesses or injuries, or prescribe medications.
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I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I have clearance from my physician to receive massage therapy.
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I understand the risks associated with massage therapy include, but are not limited to; superficial bruises or redness, short-term muscle soreness, exacerbation of undiscovered injury.
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I, therefore release the service provider from all liability concerning these injuries that may occur during the massage session.
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I understand the importance of informing the service provider of all medical conditions and medications I am taking, and to let the service provider know about any changes to these. I understand that there may be additional risks based on my physical condition.
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I understand that it is my responsibility to inform the service provider of any discomfort I may feel during the session so he/she may adjust accordingly.
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I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my personal information may be shared by the various care providers involved in my care and treatment.
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I understand that I or the service provider may terminate the session at any point in time.
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I have been given a chance to ask questions about the session and my questions have been answered.