Download informed consent to massage therapy treatment

INFORMED CONSENT OR MASSAGE THERAPY TREATMENT
I understand that the massage therapist is providing massage therapy services within their scope of practice
as defined by the American Massage Therapy Association.
I hereby consent for my therapist to treat me with massage therapy for the above noted purposes including
such assessments, examinations and techniques, which may be recommended, by my therapist.
I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other
physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical
examination. It is recommended that I attend my personal physician for any ailments that I may be
experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the
treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to
me and I assume those risks.
I acknowledge and understand that the therapist must be fully aware of my existing medical conditions. I have
completed my medical history form as provided by my therapist, and have disclosed to the therapist all of
those medical conditions affecting me. It is my responsibility to keep the massage therapist updated on my
medical history. The information I have provided is true and complete to the best of my knowledge.
I authorize my therapist to release or obtain information pertaining to my condition(s) and/or treatment
to/from my other caregivers or third party payers.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy.
By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment
discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with
my physical condition and for which I have sought treatment. I understand that at any time I may withdraw
my consent and treatment will be stopped.
Patient Name ________________________ Signature of Patient/Guardian ________________________
Witness __________________________________ Date Signed ______________________________________
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HEALTH HISTORY FORM
Name: ____________________________________
Date of initial visit: _______________
Address: __________________________________
Phone number: __________________
Date of birth: ____________________
Referred by: ______________________________
Physician name: ____________________________
Allergies: ______________________
Sports & activities: _____________________________________________________________
Current Prescription medications:
_________________________________________________________________________________________
_________________________________________________________________________________________
Are you under medical care for any of the following: (circle)
muscle spasms in neck
tightness in shoulder muscle
pain in shoulder(s)
pins and needles in hands/feet
sciatica
numbness
grating in neck
hernia
pinched nerve in back
broken bones
allergies
pregnancy
limited range of motion
Have on contact lenses
swollen/painful joints
herniated disc
heart conditions
back injury
constipation
back pain
bladder trouble
prostate problems
pain in legs and feet
chest pain
cold feet or cold hands
metal Implants or screws
bruise easily
diabetes
contagious/infectious disease
ulcers
swollen ankles
frozen shoulder
pacemaker
Crohn’s disease
nervous disorders
headaches or migraine
high/low blood pressure
fainting or dizziness
neck injury
osteoporosis
phlebitis/circulatory problems
cancer
rheumatoid arthritis
kidney disease
osteoarthritis
skin conditions
asthma/respiratory
fibromyalgia
pelvic inflammatory disease
epilepsy
whiplash
varicose veins
jaw or ear pain
other:
Have you received care from any of the following: (circle)
physiotherapist
chiropractor
massage therapist
naturopath
other: ____________________________________________________________________________________
Reason for treatment: ___________________________________________________________
Number/duration of treatments: __________________________________________________
Have you had surgery in the past?
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Y
N
If yes, for what? ________________________________
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Have you had any fractures/sprains in the past?
Have you had any serious illnesses in the past?
Y
N If yes, where? ______________________
Y
N If yes, what? ________________________
Did the current injury result from a motor vehicle accident or workplace injury?
Y
N
Have you had any of the following regarding your current condition: (circle)
physician’s examination
x-ray
other diagnostic tests
What relieves your pain? ________________________________________________________
What aggravates your pain? _____________________________________________________
On a scale of 0-10, what is your energy level?__________________
On a scale of 0-10, what is your pain level?__________ Best?_________ Worst?___________
How much water do you drink?_________________
Please indicate areas of discomfort or pain on the image below:
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Please read the following, and sign below:
I understand that the massage therapy that I receive is provided for the purpose of relaxation
and relief of muscular tension. Discomfort and pain can occur with massage therapy treatments.
I agree to immediately inform the massage therapist should I experience any pain or discomfort
during this session, or future sessions, so that the pressure and/or stroked may be adjusted to
my level of comfort. I take full responsibility for any discomfort suff ered. I further understand
that massage or bodywork should not be construed as a substitute for medical examination,
diagnosis, or treatment and that I should see a physician or other qualified medical specialist for
any mental or physical ailment of which I am aware. I understand that massage therapists are
not qualified to perform spinal or skeletal adjustments, diagnose or prescribe treatment for any
physical or mental illness, and that nothing said in the course of the session(s) given should be
construed as such. I affi rm that I have stated all my known conditions and answered all
questions honestly. I understand that massage therapy should not be performed when certain
medical conditions exist, such as (but not limited to) cancer, without physician approval.
Therefore, I agree to keep the practitioner informed of my current medical condition. I agree to
give at least 24 hours notice to cancel an appointment. Should I fail to give this proper notice I
agree to pay the full cost of the time booked.
Client Signature: ______________________________________________
Date: _____ / _____ / ____________
Consent to Treatment of Minor: By my signature below, I hereby authorize the massage therapist
to administer massage therapy to my child or dependent, as they deem necessary.
__________________________________________________
Date: _____ / _____ / ____________
Signature of Parent or Guardian
__________________________________________________
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