Consent to Massage Therapy Treatment I hereby consent for my therapist to provide treatment within their scope of practice for the purpose specified in my health history form including such assessments, examinations and techniques, which may be recommended by my therapist. I acknowledge that my 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. 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 acknowledge and understand that my therapist must be fully aware of my existing medical conditions. I have complete my medical history for as provided by my therapist and disclosed to the therapist of all those medical conditions affected me. 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 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 my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that any time I may withdraw my consent and treatment will be stopped.

    AsthmaDizziness / fainting / VertigoHigh CholesterolEmphysemaShortness of BreathPacemakerHigh Blood PressureAngina

    Hernia (Type)Low Blood PressureStrokeArthritis (Type) RheumatoidEpilepsy/SeizuresHeart DiseaseOsteoporosis / fracture related to this.

    DiabetesHeadaches/MigrainesJoint PainRheumatic FeverAngina (Chest Pain)Cancer (Type)Frequent ColdsHeart Murmurs

    Constipation / IncontinencePregnantPalpitationsDVT / Varicose VeinsMemory Loss/ Dementia /AlzheimersCirculatory Problems – Raynauds Syndrome.Depression