MASSAGE THERAPIST LIABILITY WAIVER FORM



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 ___________________________________

 

By clicking Sign & Send below you agree to the terms contained herein, and that terms are binding in your jurisdiction as defined in our Electronic Signature Disclosure & Consent

E-Sign Act Disclosure and Agreement

Your Consent To Use Electronic Records and Electronic Signatures

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Hardware & Software Requirements

Use of this Service Requirements

  1. Connection to the internet
  2. Any internet web browser with graphical interface and a pointing device, aka "a mouse" for desktop computers or a touch screen for tablets or modern phones common after 2004
  3. a PDF reader or browser capable of displaying Adobe PDF documents
  4. A printer, should you wish to print and retain a paper copy of signed documents.

Acknowledgement of your access and consent to electronic records and electronic signature

By clicking "Sign & Send" on any document posting to this service, you agree that

  • You were able to read this E-SIGN Act Disclosure & Agreement
  • Should you desire, you were able to print on paper or electronically save this agreement for future reference
  • You have an active email on file with the owner of this website
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  • You consent to receive electronically any records, notices, agreements or disclosures made to you by our client, the referring service, during the course of your relationship with that company, subject to revocation per terms above.

Electronic Signature         Disclosure & Consent