Massage Therapy Client Profile

Massage Therapist/Client Agreement

(This portion of the form will be printed for you to sign at the salon before your Massage)

I understand the massage services which I receive are designed to be a Health Aid and are in no way to take the place of a Doctor's care when such care is indicated.  I understand that massage therapists do not perform spinal or skeletal adjustments, diagnose illness, disease or any physical or mental disorders, prescribe pharmaceuticals and that nothing said during the session(s) should be construed as much.  If I have a specific medical condition or specific symptoms for which massage may be contraindicated, a referral from my primary care provider may be required before services are provided.  I take full and unqualified responsibility to keep the therapist updated as to any changes in my medical profile, and understand and agree that there shall be no liability on the therapist part should I fail to do so.  If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.  Inappropriate actions or language is cause for termination of a treatment and the client will be responsible for payment of the appointment in full.

State Law requires the following acknowledgements:  The Massage Therapist is required to have an initial consultation and discuss the type of massage they anticipated using, the parts of the body to be massaged or avoided, including indications and contraindications. 

Therapist Signature:_____________________________                                                                                                                         Client Signature:________________________________

 

I understand I will be draped during the massage and the Therapist may not engage in breast massage without written consent of the client.  The Therapist may massage the chest muscles, but if you want the breast included in your massage initial yes below.  Why massage the breast?  "...promoted as a cancer preventive...to prevent adhesions...after implant surgery...promote lactation in nursing mothers...therapeutic lymphatic massage...to deal with breast discomfort, dysfunction, trauma and disease, Massage Today Sept 2001".                             

Client's Initials Yes___  No____

I understand if I am uncomfortable for any reason I may terminate/cease the massage session and the therapist is required to end the session.  Clients Initials: _____

Because massage is contraindicated (should not be massaged) under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

Client Signature: _______________________ Date: _____________

THIS INFORMATION IS COMPLETELY CONFIDENTIAL AND TO BE USED ONLY FOR MASSAGE THERAPY!