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INFORMED CONSENT TO MASSAGE THERAPY TREATMENT |
| I hereby consent to 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
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. |
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| Patient Name:________________ |
Signature of Patient/Guardian:______________ |
| Witness:____________________ |
Date Signed:_________________________ |
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