Informed Consent Regarding Treatment

I, ____________(“Client”), hereby acknowledge the following:

  • I understand and acknowledge that the Massage Therapist/Practitioner is providing services for the purpose of relaxation, stress reduction, relief from muscular or other tension, improved flexibility and movement or the relief of pain.


  • I understand that the Massage Therapy/Practitioner service is not a substitute for medical examination, diagnosis, or treatment; and that the Massage Therapy/Practitioner does not diagnose medical conditions or prescribe medications nor does the Massage Therapy/Practitioner perform any type of spinal manipulation.


  • I acknowledge that it is my responsibility to consult with a physician prior to and regarding my/my minor's participation in any activities, programs, services or treatments, including massage therapy.


  • I acknowledge that I will immediately consult with a doctor in the case of any physical abnormality or pain before Massage Therapy.


  • I acknowledge that I am responsible to inform the Massage Therapist/Practitioner of any physical illness, injury, or medical condition that may affect the services.


  • I agree that I will follow the advice of my physician regarding my/my minor's participation in massage therapy and will notify the Massage Therapist/Practitioner of any changes in my/my minor’s physical condition.


  • I assume full responsibility for any and all risks of physical or emotional injury or damages that may arise, either directly or indirectly, from my/my minor's participation in the massage therapy services. I hereby waive, and release the Massage Therapist/Practitioner, service provider and/or owner of the practice from all liability or any injuries or damages I may sustain as a result of participating in this massage therapy service.

I have read and understand the above statements:


Participant is Age 18.

Name: Mobile Phone: Email:



Emergency Contact Name and Phone ___________________________________