SLJSpaGirl - Massage Consent Form
Formerly...Saisir Le Jour Day Spa - Saisir le jour, carpi dium...let us help you 'seize the day'...
Massage Consent Form

Please fill out ALL personal info as some people have the same name.

We want to be sure the health info is connected to the correct profile.

Massage Consent Form
Name
Phone
Address (include city & state please)
Email Address (required to submit form)
Birthdate
Occupation
Where do you feel discomfort most often?
How would you classify your stress level?
1 (Lowest)
2
3
4
5 (Highest)
Have you ever had massage therapy?
YES
NO
Check all that apply: Please check NONE if none apply
Skin allergies
Diabetes
Hypoglycemia
Stroke
Headaches
Menstruel Cramps
Referred pain
Carpal Tunnel
Rheumatoid arthritis
Varicose Veins
Osteoarthritis
Osteoporosis
HIV/AIDS
Pacemaker
Skin rash or open sores
Scoliosis/Herrington Rods
Pins & Needles (numbness)
Inner ear problems/loss of balance
Whiplash/Thoracic outlet syndrome
Fibromyalgie/Chronic Fatigue
Heart Disease/Circulatory disorder
Digestive (constipation, IBS, Crohns)
Kidney Disorders
Herniated/bulging disks
Infectious conditions
TMJ Dysfunction
Muscular Disorder
High Blood Pressure
Phlebitis/blood clots
Epilepsy/Seizures
Cancer/Malignancy
Pregnancy
Organ Transplant
ANY metal implants
Breast feeding
NONE OF THE ABOVE
Do you Smoke?
YES
NO
Are you currently taking any medications or herbal treatments?
YES
NO
Please list any Surgeries or Injuries that occurred within the last 5 years.
May I contact your physician if the need should arise?
YES
NO
Physician Name
“I certify that the above information is accurate as it concerns my safety for massage therapy and the safety of the therapist. I do not hold the therapist responsible for injuries from conditions I did not disclose. I further understand that this treatment is not sexual in any nature and that the session may be terminated with fee due for services rendered if inappropriate behavior is displayed. A drape will be required at all times and if uncomfortable for any reason I may terminate the session. “
YES
NO
“THE THERAPIST SHALL NOT ENGAGE IN BREAST MASSAGE OF FEMALE CLIENT WITHOUT THE WRITTEN CONSENT OF THE CLIENT”
I understand this statement is a state law
I give consent for massage therapy
YES
NO