Massage Therapy Consent Form

Client Information

First Namerequired
Last Namerequired
Date of Birthrequired
Emailrequired
Phone (Digits Only)required

Addressrequired
Cityrequired
Staterequired
Ziprequired

Emergency Contact Details

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

Emergency Contact Nametextrequireddb save
Contact Relationshiptextoptionalnot save
Contact Phonenumberrequireddb save

Health Data

Do you have any allergies?textoptionaldb save
Are you currently taking any medications?textoptionaldb save

optionaldb save
Are you pregnant or nursing? (Female only)
If yes, please specify on the field below.textoptionaldb save

requireddb save
Have you been recently hospitalized?
If yes, please specify on the field below.textoptionaldb save

requireddb save
Do you have any current injuries?
If yes, please specify on the field below.textoptionaldb save

Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?textoptionaldb save
Location of painful areastextoptionaldb save

Consent and Waiver

Type a question

requireddb save
I authorize

I authorize this massage spa clinic/center to perform the treatment or necessary procedure for my child.


requireddb save
I authorize

I authorize the use of lotion, oil, and ointments to my body.


requireddb save
I acknowledge

I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.


requireddb save
I understand

I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.


requireddb save
I acknowledge

I acknowledge that this massage therapy has no sexual intent and touching the therapist is strictly prohibited.


requireddb save
I release

I release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.


requireddb save
I acknowledge

I acknowledge that all information I provided int his form is true and accurate.


Date: 27.07.2022

Time: 3:23 AM

Signaturerequired
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By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You consent to be legally bound by Waiver Master's policies, terms and conditions available at waivermaster.com/terms.html and waivermaster.com/privacy.html . You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.




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