Free Massage Consent Form Template
Massage Consent Form
Please take a moment to complete this form.
Personal Information
Name
Date of Birth
Phone Number
Massage Preferences
Preferred Pressure Level
Focus Areas
Select all that apply:
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Neck
-
Shoulders
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Back
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Legs
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Arms
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Are you currently under a physician's care?
If yes, please specify
Do you have any allergies, medical conditions or recent injuries?
If yes, please specify
Are you currently pregnant?
Consent
By signing below:
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I confirm that the information provided is accurate and complete to the best of my knowledge.
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I understand that massage therapy is not a substitute for medical care and does not diagnose or treat medical conditions.
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I agree to communicate any discomfort during the session to the massage therapist.
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I release the massage therapist and the facility from any liability should I fail to disclose any relevant medical information.
Name:
Date:
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