Consent Form

Consent Form

Myofascial Release Consent Form

"*" indicates required fields

Client Information

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Email*

Phone*

Emergency Contact Details

In case of emergency, we will contact the person below.

Emergency Contact Name

First Last

Emergency Contact Phone

Health Data

Do you have any current injuries?*

Location of Painful Areas

Current Medical Conditions

Pregnant or Nursing? (Female only)

Yes

No

Consent and Waiver*

I have read and understand the Consent agreement

1. I authorize this massage spa clinic/center to perform the treatment or necessary procedure for myself or my child.
2. I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
3. I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.
4. I release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.
5. I acknowledge that all information I provided in this form is true and accurate.

Cancellation Policy*

I agree to the Cancellation policy.

I agree to a 50% fee for missed appointments not cancelled or rescheduled by 9am the day before my appointment.

Signature

CAPTCHA