Spa Day With Gwen

Massage Consent Form

Please complete this form prior to your appointment so your therapist may review it in advance.

If you have any questions, feel free to reach out and we will respond as soon as possible.

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Massage Consent Form

Spa Day With Gwen

Guendelyn Ramirez, LMT# MT144375

Remote Services/ Out-of-Establishment Services

Client's Contact Information

First name

Last name

Phone

Birthday

Month

Day

Year

Address

How did you hear about us?

Emergency Contact Name

Emergency Phone Number

Physician/Health-care Provider name:

Physician/Healthcare Contact Number

Is this massage/bodywork medically necessary (is it for a medical condition, injury, surgery)?

Yes

Do you have a physician referral/prescription?

Yes

Are you seeking insurance reimbursement?

Yes

Type of insurance coverage for this claim:

Massage Information:

Have you ever received professional massage/bodywork before?

Yes

How recently?

What types of massage/bodywork do you prefer?

What kind of pressure do you prefer?

Light

Medium

Firm

Deep

What are your goals/expected outcomes for receiving massage/bodywork?

How do you feel today?

List and prioritize your current symptoms/issues (stress, pain, stiffness, numbness/tingling, swelling, etc.):

Do these symptoms interfere with your activities of daily living (e.g., sleep, exercise, work, etc?) No/Yes, Please Explain:

List the medications you currently take (If any):

Are you wearing contacts?

Yes

Are you wearing dentures?

Yes

Are you wearing a hairpiece?

Yes

Are you pregnant?

Yes

Health Information:

Have you had any injuries or surgeries in the past that may influence today’s treatment?

Comments

Consent For Treatment:

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

I consent

Signature

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Date

Month

Day

Year