Healthcare & Wellness
Massage Therapy Consent and Agreement
Consent and service agreement for massage therapy sessions covering health disclosure, scope of treatment, and payment terms. Two signers (therapist and client).
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# Massage Therapy Consent and Agreement **Effective Date:** ___________ This Massage Therapy Consent and Agreement ("Agreement") is entered into by and between: **Therapist:** ___________ ("Therapist") **License Number:** ___________ **Client:** ___________ ("Client") ## 1. Services The Therapist agrees to provide massage therapy services to the Client as described below: **Type of Massage:** ___________ **Session Duration:** ___________ **Session Frequency:** ___________ **Session Fee:** $___________ per session ## 2. Health Disclosure and Informed Consent (a) The Client acknowledges that massage therapy is not a substitute for medical treatment, diagnosis, or prescription. The Client should continue to see their regular medical provider for any health conditions. (b) The Client represents that they have disclosed all known medical conditions, including but not limited to: cardiovascular conditions, skin conditions, allergies, injuries, pregnancy, recent surgeries, blood clots, osteoporosis, cancer, diabetes, and infectious diseases. **Known Medical Conditions or Concerns:** ___________ **Current Medications:** ___________ **Allergies (including lotion/oil allergies):** ___________ (c) The Client understands that massage therapy may occasionally cause temporary soreness, bruising, or other minor discomfort. (d) The Client agrees to inform the Therapist immediately if any technique causes pain, discomfort, or distress during the session.
Fields (17)
effective date
date · required
therapist name
text · required
license number
text · required
client name
text · required
massage type
select · required
session duration
select · required
session frequency
select · required
session fee
text · required
medical conditions
textarea
medications
textarea
allergies
textarea
cancellation notice
select · required
cancellation fee
select · required
payment method
select · required
governing state
select · required
therapist signer name
text · required
client signer name
text · required
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