Consent Form

Consent Form

Myofascial Release Consent Form

• Client Information

• Name*
  First Last
• Date of Birth*
  Date Format: 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