Fillable Printable Informed Consent for Massage Therapy

Informed Consent for Massage Therapy

NAME:

_________________________________________

(Last) (First)

INFORMED CONSENT FOR MASSAGE THERAPY

I hereby request and consent to the performance of massage therapy by the therapist/technician named

below or other therapists/technicians at Caruso Chiropractic. Massage in general provides benefits of

stress reduction, relief from muscular tension, spasm, or pain, and it increases circulation and energy

flow. I understand that massage therapists/technicians do not diagnose illness or disease, perform any

spinal manipulations, nor do they prescribe any medical treatments. I am aware that therapeutic

massage is not a substitute for medical examination and I will seek health care for those services. I

accept that massage promises no long-term results nor will it cure my health problems.

The therapist must be aware of all health conditions due to certain contraindications or cautions for

massage. I have disclosed all such conditions. I will also update any changes to my health in future

sessions.

If at any time during the massage the client or therapist/technician is uncomfortable for any reason, they

shall immediately say so.

Sexual advances of any kind will not be tolerated.

Children are not permitted in the massage room and must have childcare provided for them during the

massage. Caruso Chiropractic does not provide childcare services.

Cancellation Policy: A 24-hour notice is required for cancellation of your massage appointment. After

2 cancellations, you will be billed for the 3

cancellation if your slot is not filled. No call, no shows will

not be rescheduled after their 2

no call, no show.

All information will be kept strictly confidential and will remain with Caruso Chiropractic.

I have read and agree with above information. If I have any questions or concerns, I will let the therapist

know right away.

Signature: _________________________________________________ Date:____________________

Therapist/Technician Signature:_________________________________ Date:___________________

Massage Client Information Form

Name: _____________________________________________________ Date: ___________________

Address: _______________________________ City: _____________ State: ______ Zip: __________

Phone: (day) _____________________ (eve) ______________________ Date of Birth: _____________

Occupation: ____________________________ Employer: ____________________________________

Referred by: ____________________________ Physician: ____________________________________

Previous experience with massage: _______________________________________________________

Primary reason for massage: ____________________________________________________________

Emergency contact – name and number: ___________________________________________________

Please mark (X) all conditions that apply now. Put a (P) for past conditions,

an (F) for family history of illness

___ headaches, migraines ___ chronic pain ___ fatigue

___ vision problems, contact lenses ___ Muscle or joint pain ___ tension, stress

___ hearing problems, deafness ___ muscle, bone injuries ___ depression

___ injuries to face or head ___ numbness or tingling ___ sleep difficulties

___ sinus problems ___ sprains, strains ___ allergies, sensitivities

___ dental bridges, braces ___ arthritis, tendonitis ___ rashes, athletes foot

___ jaw pain, TMJ problems ___ cancer, tumors ___ infectious diseases

___ asthma or lung conditions ___ spinal column disorders ___ blood clots

___ constipation, diarrhea ___ diabetes ___ varicose veins

___ hernia ___ pregnancy ___ high/low blood pressure

___ birth control, IUD ___ heart, circulatory problems

___ abdominal or digestive problems___ other medical conditions not listed

Explain any areas noted above:

Current medications including aspirin, ibuprofen, herbs, supplements, etc.:

Surgeries:

Accidents:

Please list all forms and frequency of stress reduction activities, hobbies, exercise or sports participation: