MT Consent Form

I hereby request and consent to receive massage therapy and/or bodywork (specified below) from Marya DeLuna, CRMT, RMP of Wild Wellness, LLC (hereafter referred to as “the therapist” or “my therapist”).
I confirm that I am over eighteen (18) years of age.

I am choosing to receive: *

Massage Therapy Bodywork

I understand that massage therapists do not diagnose physical or mental illness, perform spinal manipulations, nor prescribe medical treatments or medications. *

Yes

I have disclosed all health conditions and current medications to my therapist, and agree to disclose changes to such prior to beginning future sessions. *

Yes

I understand that contraindications to massage therapy at the time of my session will prevent massage therapy services, and I will be charged the full service fee. *

Yes

Should I experience any discomfort during my session, I agree to immediately verbally communicate such to my therapist. *

Yes

I understand that to maintain comfort and safety, and in accordance with state laws, draping will be used by the therapist as required to expose only those parts of my body that require treatment. *

Yes

I understand that sexual behavior will not be tolerated. If such occurs, my session will be immediately terminated, and I will be charged the full service fee. *

Yes

I understand that all of my information will be kept confidential, in accordance with state laws and HIPAA guidelines. *

Yes

I understand that my therapist may assist, advise, and/or recommend; yet ultimately I am responsible for my health and wellness. *

Yes

Payment:

I understand that payment in full, via cash or credit card, is due at the time of service. *

Yes

Cancellation Policy:

24 hours’ notice is required to cancel a session. If a session is cancelled within less than 24 hours, I understand that I will be charged 50% of the service fee. *

Yes

I understand that tardiness on my part may prevent a full session, and that the original service fee will be maintained. *

Yes

Name *

First

Last

Date *

Massage Therapy Consent Form

Payment:

Cancellation Policy: