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I hereby consent for my therapist to treat me with massage therapy. The process of treatment is including interview, assessments, hydrotherapy, techniques and exercises, which are recommended by my therapist.
I acknowledge that the Registered Massage Therapist (RMT) is providing massage therapy services within the scope of practice as defined by the massage therapy regulating body in the State or Province.
I understand that my therapist must be aware of any of my previous and/or existing medical conditions. I have disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to update my therapist on my medical history or any changed in my medical conditions. The information I have provided to my therapist is true and complete to the best of my knowledge.
I acknowledge that the therapist is not a physician and can not diagnose my disease or condition. I clearly understand that massage therapy is not a substitute for a medical examination and I will seek my Physician expert opinion about my condition when needed. 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 side effects and those risks and side effects have been explained to me and all my questions in this regard have been addressed and I assume those risks or side effects.
I have read the above noted consent and I have had the opportunity to ask any question before I sign this consent form. By signing this form, I confirm my consent to treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.
I understand the cancellation policy of the clinic, and that I must provide at least 24 hour notice of cancellation of an appointment. I understand that I may be charged the full fee for a missed appointment if proper cancellation notification is not provided to the clinic.
Therapist name :