Name *

First Name

Last Name

Consent/Waiver of Liability *

If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure &/or strokes may be adjusted to my level of comfort. I further understand that Massage should not be construed as a substitute for medical examination, diagnosis, or treatment & that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. Because Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, & answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile & understand that there shall be no liability on the therapist’s part should I fail to do so. This is an Energetic Massage session & any sexual advances will terminate the session & I will be liable for payment of the scheduled treatment. I understand the Massage Therapist practitioner reserves the right to refuse services to me for any reason that she deems necessary. If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours, you will still be responsible for the full cost of session.

I Agree