Informed Consent for Massage Therapy

Patient Name:________________________________________ Date of Birth:______________________

I understand that the massage provided by the licensed massage therapist at Mt. Rainier Clinic uses techniques that manually manipulate the muscles, tendons, and fascia of the body to promote health and wellness. Benefits of massage include stress reduction, circulation enhancement, increased relaxation, and relief from muscular tension, soreness, and pain.

I understand that the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of massage therapy.

I understand that massage therapy is not a substitute for medical care and that it is recommended that I work with my primary care provider for any condition I may have.

I understand that massage therapy may lead to adverse reactions in certain situations or when used with certain conditions or medications. The massage therapist will evaluate your health-history intake and ask you questions to make sure it is safe for you to receive massage therapy. In the event the massage therapist is uncertain that massage will be of benefit to you, he or she may ask you to provide a referral from your physician stating that it is safe for you to receive massage. Please provide complete details of medical conditions and medications to your massage therapist during the health-intake interview. Failure to inform the massage therapist of all medical conditions and medications may place you at increased risk for adverse reactions.

I have stated all my known physical conditions and medications, and I will keep the massage therapist updated on any changes. I release the massage therapist of any liability if I fail to disclose the appropriate health-related information.

I have read this form and fully understand its content and agree to receive massage therapy provided at Mt. Rainier Clinic.

_________________________________________________Patient Name (please print)

_________________________________________________ ________________________Patient Signature Date