Massage Therapy Consent Form
You will electronically sign your form before your service. You only need to complete this form the first time you visit.
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Name
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Date
MM
/
DD
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YYYY
Occupation
Sports/Hobbies
Please indicate where you are feeling pain/discomfort
Other comments
Describe your sleep patterns
Difficulty laying in a certain position
List any major surgeries you have had in the last 5 years
List any serious or lasting trauma (MVA etc.)
Emergency Contact *
Have you had previous massages? *
Are you receiving care from other medical professionals
CARDIOVASCULAR - current or recently experienced
List medications taken for these conditions
RESPIRATORY - current or recently experienced
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List medications taken for these conditions
DIGESTIVE - Indicate conditions currently or recently experienced
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List medications taken for these conditions
HEART & NECK - Indicate conditions currently or recently experienced
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List medications taken for these conditions
MUSCLE / JOINT / BONE - Indicate conditions currently or recently experienced
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List medications taken for these conditions
INFECTIOUS CONDITIONS (PRESENT)
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List medications taken for these conditions
WOMEN
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WOMEN
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If pregnant, how many weeks along?
List medications taken for these conditions
OTHER CONDITIONS
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List medications taken for these conditions
SKIN CONDITIONS (NON-CONTAGIOUS)
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List medications taken for these conditions
I release my massage therapist from any and all liability from problems arising for my treatments as a result of information not given, or incorrectly given in the patient history and consultation prior to my massages. Because my personal and medical information is confidential, I understand that none of this information will be shared with any third parties unless I give my consent in writing. My therapist may recommend cupping to me as an alternative way to release tissues/muscles. If cupping is agreed to, I will communicate to my massage therapist any physical discomfort during the sessions. I have fully disclosed all health factors to my therapist, including those not mentioned on this Massage Consent Form to avoid any complications. It has been explained to me that there is a possibility of bruising from the release and clearing of stagnation and toxins from my body with cupping. I further understand that this will dissipate after a few days to a week. Clients and practitioners will refrain from alcohol or recreational drug use for at least 12 hours prior to any appointment. Clients who are taking prescription or over-the-counter drugs, including medically prescribed cannabis for pain management or anti-inflammatory purposes, should inform the therapist prior to the session.
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