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I hereby consent for the Massage Therapist to treat me with massage therapy including such assessments, examinations and techniques, which may be recommended, by the Therapist.

I acknowledge that I am aware the Therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination and it is recommended that I consult my 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 further understand that with any treatment there can be risks and those risks have been explained to me and I assume those risks.

I acknowledge and understand that the Therapist must be fully aware of my existing medical conditions. It is my responsibility to keep the Massage Therapist updated on my medical history. The information I have provided is true and complete to the best of my knowledge.

I authorize the Therapist to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third party billing companies.

I have read the above noted consent and I have had the opportunity to question the contents and my 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 as proposed by the Therapist from time to time, to deal with 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.


Patient name ____________________________________________




Witness ________________________________________________


Therapist __Massageworks_RMT____________________________