CONSENT FOR TREATMENT
I, ____________________, (or the patient named below for whom I am legally responsible),
hereby request and consent to receive massage therapy and related care by Laurie Higginbotham,
CACMT, who now or in the future may treat me while working at or associated with Born
Naturopathic, whether signatories to this form or not.
I understand that the massage given to me by _______ is for the purpose of (stress reduction,
pain reduction, relief from muscle tension, increasing circulation, or specific reasons stated here).
I understand that the massage therapist does not diagnose illness or disease and does not
prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage
therapy.
I understand that massage therapy is not a substitute for medical care and that it is recommended
that I work with my primary caregiver for any condition I may have.
I have stated all my known physical conditions and medications, and I will keep the massage
therapist updated on any changes.
I have had the opportunity to discuss with the massage therapist at Born Naturopathic the nature
and purpose of massage treatments and procedures. I understand that if I receive treatment, table
or chair massages, the risks included but not limited to: local bruising, dizziness, temporary pain
or discomfort and the possible temporary aggravation of prior existing symptoms. I do not
expect the practitioner to be able to anticipate and explain all risks and complications, and I wish
to rely on him/her to exercise judgment during the course of the procedure which he/she feels at
the time, based on the facts know then, is in my best interest/
I understand that some treatments, herbs and supplements may be inappropriate during
pregnancy, and I will immediately notify the therapist if I become aware that I am pregnant.
I will immediately inform the therapist if I experience any gastrointestinal upset (nausea, gas,
stomachache, vomiting or similar condition), allergic reactions (hives, rashes, tingling of the
tongue, headache or similar condition), or any unanticipated or unpleasant effects associated with
treatment, or the herbs, or other supplements prescribed by the therapist. I understand that while
this document describes the most common risks of treatment, other side effects and risks may
occur. I understand that in order to properly treat my medical condition, the therapist must be
contacted promptly if an adverse reaction or condition occurs. In any event, if an emergency
Born Naturopathic Associates, Inc.
512 Westline Dr., Suite 204
Alameda, CA 94501
510-550-4023
medical condition arises, I understand that I am to seek treatment immediately from a trauma
center or call 9-1-1.
I have read, or have had read to me, the above information and consent. I have also had an
opportunity to ask questions about its content, and by voluntarily signing below I agree to the
above-named procedures. I intend this consent form to cover the entire course of treatment for
my present condition and for any future condition(s) for which I seek diagnosis and treatment.
__________________________________
(Patient/patient’s representative signature)
___________
(Date)
_______________________________________
(Printed name of patient/patient’s representative)
____________
(Date)
If you are the patient’s representative, indicate relationship and basis of representative’s
authority to act for patient:
*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*
Born Naturopathic Associates, Inc.
512 Westline Dr., Suite 204
Alameda, CA 94501
510-550-4023