Fillable Printable Massage Therapy Informed Consent - Ohio

Massage Therapy Informed Consent - Ohio

Patient’s Name (please print):Date:

Please carefully read the following information and sign where indicated.

If you have certain medical conditions or symptoms, massage therapy may be problematic for you. A referral from

your primary health care provider may be required prior to treatment being provided.

If at any point during the massage I am uncomfortable or uneasy with the procedures being administered and/or if

I experience pain, I understand it is my responsibility to IMMEDIATELY inform the massage therapist, so that the

procedures can be adjusted to a level of comfort or terminated.

I further understand that massage therapy is not a substitute for diagnosis and treatment by a medical or

osteopathic doctor. What we discuss is not a replacement for their advice.

I understand that the Massage Therapy Scope of Practice (found in Ohio Revised Code 4731.15 and Administrative

Rules 4731-1-05) does not include thrusting spinal adjustments or the use of drugs, diet, or exercise.

I agree to provide complete and accurate information about my health history today, and to tell my therapist about

any changes in the future. If I do not, it may affect my therapy, or result in the termination of our relationship.

For patients under the age of 18, we recommend the parent/guardian meet the therapist at the time the waiver is

signed. It is not required for the parent/guardian to stay in the room or on premises, but they have the choice to

do so.

I agree to keep to the following rules on each visit:

Before each treatment

• Tell your therapist about any changes in your health since your last visit.

• Please remove all jewelry. If you wear a wedding band or other item that you need to leave on, please

let us know.

• Ask your therapist if it is best to bind long hair up on your head.

MASSAGE THERAPY INFORMED CONSENT

And throughout your visit

• Please ask questions about the procedures. Your therapist will be happy to keep you informed and

comfortable.

• Always inform your therapist immediately upon any pain or discomfort.

• Refrain from making illicit or sexually suggestive remarks or actions. Any such behavior will result in

immediate termination of the treatment.

Parent/Guardian

Signature (If under 18):

Date:

Patient’s Signature: