MASSAGE CLIENT INFORMATION AND CONSULTATION FORM – Consent Forms- Med Spa at Villagio

Name

DATE

OCCUPATION:

Please circle below all that apply: Spinal Problems , Allergies, High Blood Pressure , Bruise Easily , Varicose , Veins , Migraines , Injuries ,Heart Conditions Smoker ,Pregnant Please explain any circled above:

Any medical conditions or medications your therapist should be made aware of

Type of massage you are requesting: Swedish/Relaxation Deep Tissue Hot Stone Prenatal Massage Reflexology Sports Areas of pain/tension:

Areas to be avoided:

Client Acknowledgement Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals, and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis I must provide a physician’s written consent prior to services. The massage therapist will not perform breast massage on female clients without the writing consent of the client prior to the massage session. Draping will be used during the massage session unless otherwise agreed to in writing by both client and therapist. If uncomfortable for any reason, the client or therapist may ask to end the massage session, and the session will be ended. *Consent to Treatment of Minor: If under the age of 17, parent or guardian must sign for the minor: with my signature below, I hereby authorize my dependent to receive a massage. CLIENT SIGNATURE:

Date

To be filled out by Massage Therapist

Date