top of page

Client's Information/Consent

Describe the pain (if any)

Consent for Treatment with Therapeutic and Relaxation Massage Clinic

I am hereby requesting Massage treatments from contracted massage therapists at Therapeutic and Relaxation Massage Clinic which include relaxation, deep tissue, prenatal, essential oil, hot stone and cupping massage. New complications and concerns, if they do arise, will be discussed with my practitioner, and appropriate action will be taken. I understand that although these are natural and alternative treatments, I am seeking, there may be risks of bruising, pain in treated area, and worsening of symptoms during the healing process. I hereby release Therapeutic and Relaxation Massage Clinic and all practitioners/therapists treating me from all liabilities.

I am also aware of the clinic's late cancellation policy of a charge of 50% of the visit cost if I fail to give less than 24 hours notice for cancellation, I will be responsible to pay that charge before I can re-book. 

Thanks for submitting!

Pregnancy Massage Client's Intake From

Consent for Pregnancy Massage with Therapeutic and Relaxation Massage Clinic

I have read this entire form including the contraindications listed above. I attest that I have none of the above conditions, nor do I have any medical problems whatsoever. I am in general good health. I am aware that I am being massaged by. I agree to hold my massage therapist and Massage Therapy Connections harmless in the event of any medical/health problem being experienced by me during or after the massage. I have read and I understand what has been stated above. I have answered all questions and have supplied personal information honestly and accurately. I realize that if I have been dishonest I could be endangering my or my unborn child’s health.

Thanks for submitting!

Minor Consent From

Minors are permitted to receive massage in the clinic.

Parents or legal guardians must be present in helping complete the Health History Form for the minor, along with consent for the massage therapy session.


  • All minor clients under the age 18 can only receive massage with written parental/legal guardian consent.

  • parental/legal guardian should be in the treatment room during each session.

  • In collaboration with the consenting adult and child, the massage therapist will assist in establishing goals for the session.

  • Appropriate draping will be always used during the massage, only areas being massaged are uncovered.



am the parental/legal guardian of,


I have read the above information and give permission for my child,            

To receive massage therapy from    


Thanks for submitting!

bottom of page