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Informed Consent for Massage Therapy

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Informed Consent for Massage Therapy

NAME:

I hereby request and consent to the performance of massage therapy by the therapist/technician named below or other therapists/technicians at Caruso Chiropractic. Massage in general provides benefits of stress reduction, relief from muscular tension, spasm, or pain, and it increases circulation and energy flow. I understand that massage therapists/technicians do not diagnose illness or disease, perform any spinal manipulations, nor do they prescribe any medical treatments. I am aware that therapeutic massage is not a substitute for medical examination and I will seek health care for those services. I accept that massage promises no long-term results nor will it cure my health problems.

The therapist must be aware of all health conditions due to certain contraindications or cautions for massage. I have disclosed all such conditions. I will also update any changes to my health in future sessions.

If at any time during the massage the client or therapist/technician is uncomfortable for any reason, they shall immediately say so.

Sexual advances of any kind will not be tolerated.

Children are not permitted in the massage room and must have childcare provided for them during the massage. Caruso Chiropractic does not provide childcare services.

Cancellation Policy: A 24-hour notice is required for cancellation of your massage appointment. After 2 cancellations, you will be billed for the 3rd cancellation if your slot is not filled. No call, no shows will not be rescheduled after their 2nd no call, no show.

All information will be kept strictly confidential and will remain with Caruso Chiropractic.

I have read and agree with above information. If I have any questions or concerns, I will let the therapist know right away.

Massage Client Information Form

Name: Date:

Address: City: State: Zip:

Phone: (day) (eve) Date of Birth:

Occupation: Employer:

Referred by: Physician:

Previous experience with massage:

Primary reason for massage:

Emergency contact – name and number:

Please mark (X) all conditions that apply now. Put a (P) for past conditions, an (F) for family history of illness

headaches, migraines

vision problems, contact lenses

hearing problems, deafness

injuries to face or head

sinus problems

dental bridges, braces

jaw pain, TMJ problems

asthma or lung conditions

constipation, diarrhea

hernia

birth control, IUD

abdominal or digestive problems

chronic pain

Muscle or joint pain

muscle, bone injuries

numbness or tingling

sprains, strains

arthritis, tendonitis

cancer, tumors

spinal column disorders

diabetes

pregnancy

heart, circulatory problems

other medical conditions not listed

fatigue

tension, stress

depression

sleep difficulties

allergies, sensitivities

rashes, athletes foot

infectious diseases

blood clots

varicose veins

high/low blood pressure

Explain any areas noted above:

Current medications including aspirin, ibuprofen, herbs, supplements, etc.:

Surgeries:

Accidents:

Please list all forms and frequency of stress reduction activities, hobbies, exercise or sports participation:

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What an Informed Consent for Massage Therapy Is and why it matters

An Informed Consent for Massage Therapy is a written record that documents a client’s voluntary agreement to receive massage treatment after being informed about the nature, scope, benefits, and possible risks of the therapy. It typically collects health history, current medications, relevant diagnoses, areas to avoid, and any specific contraindications that may influence treatment. The form creates a clear, auditable record of disclosure and client consent, supports clinical decision-making, and can be executed electronically under the ESIGN Act (15 U.S.C. ch. 96) or state UETA laws where applicable when the signer demonstrates intent, consent, attribution, and retained reproducibility.

Why a clear informed consent improves care and reduces risk

A properly drafted consent clarifies treatment goals, documents client disclosures, and sets expectations for both the practitioner and client; it also supports risk management and professional standards.

Why a clear informed consent improves care and reduces risk

Who typically completes the consent and where it’s used

Licensed practitioners and organizations collecting consent before massage therapy sessions.

  • Licensed massage therapists and bodywork practitioners providing direct client care and documenting clinical decisions.
  • Private clinics and day spas maintaining patient records, treatment logs, and liability documentation for audits.
  • Sports medicine teams and rehabilitation clinics integrating consent with intake, treatment plans, and release forms.

The form is also used by clinics, spas, sports teams, and educational programs to document acceptance and exclusions.

Core elements every professional informed consent should include

A complete consent form balances clear language for the client with fields that capture essential clinical and legal information, structured to support clinical judgment and recordkeeping.

Patient identity

Full legal name, date of birth, contact details, and emergency contact to ensure correct patient matching and follow-up.

Medical history

Relevant conditions, surgeries, current medications, pregnancy status, and recent injuries that could affect treatment safety.

Contraindications

List of conditions or local contraindications where massage should be modified or withheld, such as deep vein thrombosis or open wounds.

Treatment description

Planned techniques, session length, frequency, and any use of oils, heat, or adjunct modalities that the client should expect.

Risks and benefits

Clear, concise summary of common benefits and potential adverse effects, including soreness, bruising, or adverse reactions.

Consent and signatures

Signature, printed name, date, and provider attestations that informed the client and answered questions before treatment.

Essential data fields to capture on the form

Client name: Full legal name
Date of birth: MM/DD/YYYY
Contact information: Phone, email, street address
Emergency contact: Name and phone
Medical summary: Key conditions/medications
Signature block: Signed name and date

Stepwise process to complete and record the consent

Follow these sequential steps before the first treatment to confirm informed decision-making and preserve a complete record.

  • 01
    Review the form: Read all sections and ask clarifying questions.
  • 02
    Provide medical details: Enter full health history and current medications.
  • 03
    Confirm treatment plan: Agree on techniques, duration, and areas of focus.
  • 04
    Sign and date: Sign electronically or on paper before therapy begins.

How to configure an online consent workflow

Set up the digital workflow to enforce required fields, capture audit data, and route completed records into secure storage.

Field Online Setting
Required fields Mark name, DOB, medical history, signature required
Conditional fields Show pregnancy and medication fields only when applicable
Signature type Allow typed, drawn, or cryptographic signature
Authentication Use email verification or SMS code for signer identity

Where to send the completed consent and how it’s routed

Define destinations for signed consents to ensure clinical access and compliance during audits or insurance review.

  • Client copy: Email or provide downloadable PDF to client
  • Clinic chart: Save signed form to the patient’s electronic record
  • Referring provider: Share with physician when treatment coordination required
  • Billing records: Attach to invoice or insurance submission as needed

Options for distributing and collecting consent forms

Choose secure delivery channels that preserve integrity, authentication, and an audit trail for each signed consent.

  • Secure email: Encrypted transmission of PDF copy
  • Patient portal: Centralized storage with access control
  • In-clinic tablet: Kiosk or tablet capture at point of care

Timing rules and recommended review cadence

Establish timing rules so consent is current, clearly documented, and revisited when clinical conditions change.

Prior to first visit:

Obtain and sign consent before any treatment begins

Treatment changes:

Update consent when modality or risk profile changes

Annual review:

Reconfirm consent and updated history at least yearly

Minor patients:

Secure parental/guardian consent per state rules

Retention trigger:

Keep signed record per applicable retention schedule

Common preparation mistakes to avoid

  • Failing to obtain a signature before treatment starts increases dispute risk and may invalidate claimed consent in adverse events.
  • Collecting incomplete medical history—omitting medications or recent procedures—can lead to unsafe treatment choices and liability exposure.
  • Using vague language about risks or techniques leaves expectations unclear and weakens informed consent defensibility in claims.
  • Improper storage or unsecured email delivery of signed forms can create privacy violations and HIPAA breach liability.

Key legal and professional risks from deficient consent

Professional liability: Claims for negligence or malpractice
Informed consent challenge: Court may find consent invalid
HIPAA exposure: Civil monetary penalties and corrective action
Insurance denial: Claims or reimbursements may be refused
Regulatory discipline: State board sanctions possible
Patient harm: Adverse events with increased liability

Cost considerations for e-signature platforms used with consent forms

Platform choice affects per-user cost, enterprise features like bulk send, HIPAA support, and whether envelope or usage limits apply.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies Varies Varies Varies
Bulk Send Yes Yes Yes Yes Varies
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently asked questions about Informed Consent for Massage Therapy

Answers to common questions about form validity, e-signatures, minors, recordkeeping, and what to do when a client revokes consent.


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