• The following information will be used to help plan a safe and effective massage session. Please read the questions on the next page carefully and answer each one honestly:
  • Medical History

  • Provisions of the massage:

    During your massage, the Therapist may use Swedish, deep tissue, cross fiber, trigger point, MFR, and other approved techniques to facilitate the massage. The Therapist will massage the necessary body parts to facilitate the massage excluding any contraindicated areas. The Therapist will not work the breast area without written consent by the client. Proper draping will be used throughout the massage. If at any time the client is uncomfortable with the massage, the Therapist will discontinue the massage.
  • Massage Waiver:

    Massage therapy is not a substitute for medical examination and diagnosis. It is recommended that I see a physician for any physical aliment that I may have. I understand that the Therapist does not diagnose illness, disease or any other physical or mental disorder. Likewise, the therapist does not prescribe medical treatment or pharmaceuticals, nor does the Therapist perform spinal adjustments. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, will inform the Therapist of changes in my health status, and understand that there shall be no liability on the practitioners part should I fail to do so. I have read and understand the questions about the statements regarding the client waiver.
  • Additional Information:

    Therapeutic massage may cause discomfort for 1 to 3 days following treatment. I understand that this is a normal phase of the healing process & is a reflection of my body healing. I further understand that drinking water will facilitate the healing process & that drinking water is in my best interest. I also understand that emotions may be stored in my tissues & release of the restrictions may also cause a release of emotions. Too is a normal phase of the healing process and is a reflection of my body healing.
  • This field is for validation purposes and should be left unchanged.