INFORMED CONSENT TO MASSAGE THERAPY TREATMENT

I understand that the bodywork therapist/practitioner is providing bodywork/massage therapy services within
their scope of practice as defined by the RMQ & associations to which she belongs to.

I hereby consent for my bodywork therapist/practitioner to treat & perform services for the above noted
purposes including such assessments, examinations and techniques, which may be recommended, by my
therapist/practitioner.

I understand that the purpose of this bodywork/massage is for relaxation and not meant to diagnose or treat
any illness, disease or any other physical or mental disorder, injury or condition. If I have a specific medical
condition or symptom, receiving or performing bodywork/massage may be contraindicated or require
modification. A referral from my primary care provider may be requested prior to receiving and/or performing
bodywork/massage.

I will not hold The massage Therapist liable for any injury or similar condition that arises from the application
of bodywork/massage. I hear by attest that I am here today and at any subsequent session on my own
personal behalf, to receive bodywork/massage/Thai Yoga Massage & therapeutic modalities.

l recognize that the services offered by The massagetherapist do not involve medical diagnosis and I
acknowledge that the therapist/practitioner is not a physician and does not diagnose illness or disease or any
other physical or mental disorder. I clearly understand that bodywork/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 take full responsibility for my own well being as it relates to this/these sessions.

I acknowledge and understand that the therapist/practitioner 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 disclose and to keep the
therapist/practitioner updated on my medical history. The information I have provided is true and complete
to the best of my knowledge.

I authorize my therapist/practitioner to release or obtain information pertaining to my condition(s) and/or
treatment to/from my other caregivers or relevant third party.

I have read the above noted consent and I have had the opportunity to question the contents and my
bodywork/ massage 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 they may propose from time to time.
my therapist/practitioner to support 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.
I confirm that all the information supplied in the present file is true.