Massage Consent Form

For massage appointments 

Please fill out this form if you are attending a massage appointment. For pregnancy massage please fill out my pregnancy massage form.

  • Using the diagram below as a guide please fill out the following fields to indicate any pain, stiffness or numbness. Areas of Pain Image supplied by Burrell Education.
    I regularly send out an email newsletter with tips, and information about women’s health and fitness. Please confirm if you would like to receive this by email.
  • Please tick to confirm that you agree to our privacy policy regarding how we use your information.
  • I understand that the massage I receive is provided for the basic purpose of relaxation and relief of muscular tension and myofascial pain conditions suitable for treatment using soft tissue therapies.

    If I experience any pain during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or qualified medical specialist for any mental or physical ailment of which I am aware.

    I understand the massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly.

    I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.

    I acknowledge that should I be late for my appointment the therapist has the right to alter the length of my massage to suit the needs of the office schedule.

    I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.

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