Massage Therapy Consent Form

Massage Therapy Consent Form

Please fill this out before your scheduled appointment.
Client Information
Name

First NameLast Name
Age/Occupation
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Details
Emergency Contact Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing? (Female only)
If yes, please specify on the field above.
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
I authorize this massage spa clinic/center to perform the treatment or necessary procedure for my child.I authorize the use of lotion, oil, and ointments to my body.I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.Type a questionI release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.I acknowledge that all information I provided int his form is true and accurate.
Signature of the Client

Clear
Date Signed

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Address: 2080 York Road Timonium MD 20193. Please arrive 2nd Level Upstairs Red Sign says Phenix. Turn left then proceed down the hallway to the left Suite 111 Entrance.
*Flu season is here! Please text us to reschedule in advance 24 hours of your Appointment if you are coughing, sneezing, or flu/COVID-19 like symptoms.
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Date

MonthDayYear
Date
Phone Number

Area CodePhone Number
Should be Empty:

Massage Therapy Consent Form

Client Information

Emergency Contact Details

Health Data

Consent and Waiver