Consent & Liability form for Rejuvenation Massage
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COVID-19 & TMJ Therapy :!
I understand that Caroline Brady will be in close contact with me, this includes touching my
scalp, face & neck as well as working inside my mouth. Given the nature of this type of
therapy I will not be able to wear a mask during my treatment. Even though Caroline will be
wearing a mask & gloves, I am aware that my risk of exposure to COVID-19 is increased. By
signing this form I acknowledge that I am aware of the risks involved and give consent to
receive massage from this practitioner. !
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TMJ Therapy :!
I understand that by choosing to receive TMJ therapy from Caroline Brady this will include
massage of my scalp, face & neck as well as working inside my mouth. I give Caroline consent
to perform the above described therapy on me.!
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Massage in general :!
I understand that the massage I receive is for relief of muscular tension and relaxation. If I
experience any pain or discomfort during my session I will inform Caroline so that the pressure
or stroke can be adjusted to my comfort level. I understand that massage is not a substitute
for any type of medical exam, diagnosis, or treatment & that I should seek the assistance of the
appropriate medical (physical or mental) practitioner. I understand that a massage therapist
cannot perform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or
mental illnesses and that nothing said during a session should be construed as such. Because
massage should not be performed under certain medical conditions, I affirm that I have stated
all known medical conditions and have answered all questions honestly. I agree to keep the
therapist updated as to any changes in my medical profile and understand that there should be
no liability on the therapists part should I fail to do so. I understand that any illicit or sexually
suggestive remarks or advances made by me will result in immediate termination of the
session. I also understand that Caroline Brady has the right to refuse to perform massage on
anyone whom she deems to have a condition for which massage is contraindicated. !
Draping : I understand that if draping is part of my session, only the area being treated will be
uncovered, this may include the top of the gluteal cleft and areas near breast tissue.!
I give consent for Caroline Brady to use hydrotherapy & cupping during my session if she feels
its beneficial to my care, unless I (the client) specifically ask her not to. !
Informed written consent must be provided by a parent or legal guardian for any client under
the age of 17yrs.!
I, __________________________________ have read and agree to the terms provided above. !
Initial date: !
Future dates:
