Client Consent and Waiver

Massage Patient Information & Informed Consent Form

  1. I understand that massage therapy and body work services are a therapeutic health aid and are non-sexual. I understand my massage therapist reserves the right to end a therapy session in the case of sexual innuendo or advances from the client. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the massage, and I will be liable for full payment of the scheduled session.
  2. Any information exchanged during a massage or body work session is confidential and is only used to provide me with the best health care services available. I understand that a massage therapist will ask me questions about my health and physical condition and that I am obligated to answer truthfully and honestly about my health history in full detail.
  3. I understand that my feedback is essential in my treatment, and that if I experience any unusual discomfort and/or pain during my massage session, it is my responsibility to inform the therapist in order to enable the therapist to adjust the pressure or technique being used.
  4. The therapist reserves the right to decline, discontinue, or restrict services based on any provided information that may indicate that massage therapy would put my health or the therapist’s health at risk.
  5. I acknowledge that I am responsible to be on time for my appointments and that the therapist is not under any obligation to extend my therapy session. I also agree that I am responsible to pay for the full time I have booked with the therapist if I am late. I understand that my appointment time is reserved for me only. If I miss an appointment or am unable to give twenty four (24) hours’ notice when I need to change or cancel my appointment, I agree to pay the company in full for the booked appointment time. I further understand that I will be additionally charged $30.00 for any returned checks.
  6. I understand that the practitioner does not prescribe medical treatment of pharmaceuticals, nor does he/she perform any spinal manipulations.
  7. I understand that service offered today, and in the future, are not a substitute for medical care and that any information provided to me by the therapist is purely for educational purposes and is not diagnostically prescriptive in nature.
  8. I have stated all of my known medical conditions on the Client Intake Form. I have consulted a medical doctor or licensed medical health care practitioner regarding any checked or described conditions. 
  9. I understand it is my sole responsibility to keep the therapist updated on any changes in my physical health and I further understand that the company and the therapist shall not be liable for any purpose and for any reason whatsoever, should I fail to inform the therapist.
  10. I have reviewed this form in its entirety and I have discussed all my concerns regarding my treatment with my massage therapist.

 

By signing this Informed Consent and Waiver, I consent to receive therapy at Dynamic Mobility and hereby agree to all policies of the company, and waive and release Dynamic Mobility and its massage therapists from any and all past, present and future liability, loss, cost, claim or damage whatsoever which may be imposed upon the Company relating to massage therapy and sports training; including but not limited to reflexology, acupressure, nutritional therapies, all forms of kinesiology, myofascial release therapy, manual technique therapies, trigger point therapy, stretching therapy, strength and condition training, among others. I further undertake to indemnify and hold Dynamic Mobility harmless from any incident(s) arising from my use of Dynamic Mobility Sports Massage and Training services by signing below.

 
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