Massage Treatment - Informed Consent
I (client’s name) ___________________________ understand that by signing this form I am choosing to proceed with and freely give my permission to
receive massage therapy treatment from Terrina N. Mason
Please initial
_____I understand that all information given to Terrina N. Mason will be strictly confidential. The only time my information may be seen by anyone other
than myself or the massage practitioner is with my written consent.
_____I understand that any assessment done by Terrina N. Mason cannot diagnose a problem, but is used as a measure to rule out any potential
contraindications to massage.
_____I understand that massage practitioners do not diagnose illness or disease or perform any spinal manipulations, nor do they prescribe any medical
treatments, and nothing said or done during the sessions should be construed as such.
_____I understand that massage therapy is not a substitute for medical examination, diagnosis and/or treatment and that I should seek a medical or
chiropractic physician, alternative health care specialist, or registered massage therapist to address concerns that are outside the scope of Terrina N.
Mason’s practice.
_____I understand that massage is contraindicated for some medical conditions and that it may be necessary to obtain a physician’s clearance or release
before beginning treatment.
_____I understand that Terrina N. Mason is a massage practitioner and not a Registered Massage Therapist.
_____I understand that the massage I receive is for the purpose of stress reduction and relief from muscular tension, spasm or pain and to increase
circulation. If I experience any pain or discomfort, I will immediately inform Terrina N. Mason so that the pressure or methods can be adjusted to my
comfort level.
_____I understand that there are possible risks involved in massage treatment that may include: muscle, tendon, ligament, bone and joint soreness;
bruising; aggravation of an existing or past injury; dizziness; possible discomfort; and I accept these and all risks associated with massage treatment.
_____I understand that I may change my mind, alter or refuse massage treatment at any time during this or any subsequent visit.
_____I understand that I will be draped during treatment, that only the body part being massaged will be exposed, and that I may request additional
draping if desired.
_____Because massage therapy should not be performed under certain circumstances, I confirm that all information on my health history form is correct
and up to date, I agree to keep Terrina N. Mason updated as to any changes in my health, and I release Terrina N. Mason from any liability if I fail to do
so.
_____I understand that I am responsible for any charges incurred in the course of my massage treatment.
_____I understand that 24 hours notice is required to reschedule all future appointments, or full charges will apply.
_____I, the applicant on behalf of myself, members of my family, my heirs, executors, administrators and assigns, hereby forever release, discharge and
hold harmless Terrina N. Mason for any injury, loss of damage to my person or property howsoever caused, arising out of or in connection with my taking
part in massage treatment and notwithstanding that the same may have been contributed to or occasioned by the negligence of the above mentioned
massage practitioner.
I declare that I have read, understood and agree to contents of the Informed Consent in its entirety.
Client’s Signature: _________________________________
Date:________________________________
Practitioner’s Signature: ______________________________
Date: _______________________________
Signature of Guardian/Substitute Decision Maker:________________________
Date:________________________________