Massage Therapy Consent Form To tailor your massage specifically to your needs please answer the following questions1. Have you ever had a massage before?(Required) Yes No 2. What pressure would you like the Massage Therapist to use during the massage?(Required) Unsure Light Moderate Deep 3. During my massage, I prefer:(Required) Quiet and relaxing, having the therapist check in occasionally, and leaving education until the end Chat and catch up with my therapist A little of both Payment InformationPayment Information(Required) I understand that payments for services at Palermo + Physiotherapy and Wellness Centre are my responsibility after every service is received. If my claim is to be submitted to an outside agency for payment, and for any reason the third-party payer, such as insurance or employer denies and/or refuses to pay for the full amount I am billed, I am responsible for payment.Massage Therapy Fees (including HST)30-Minute Massage: $70.0045-Minute Massage: $90.0060-Minute Massage: $111.0075-Minute Massage: $130.0090-Minute Massage: $155.00 Cancellation of AppointmentCancellation of Appointment(Required) Palermo + Physiotherapy & Wellness requires a minimum of 24 hours notice for any appointment cancellations. Should you give less than 24 hours notice, a $45.00 cancellation charge may be charged. Your appointment time has been reserved specifically for you. Should you book an appointment and not to attend, you are responsible to pay for the entire cost of the appointment. Informed Consent for Assessment and Treatment (Massage Therapy)Informed Consent for Assessment and Treatment (Massage Therapy)(Required) During your initial visit, the Massage Therapist will discuss treatment recommendations and techniques. Massage Therapy involves the manipulation of the soft tissues of the body, skin, muscle, ligaments and connective tissues, using techniques to produce therapeutic results.With Massage Therapy, the client disrobes to their comfort level, and lies on a table between two sheets. Only the areas of the body being directly treated are uncovered at one time. If at any time you are uncomfortable with the pressure or technique being used, you can ask the therapist (i.e. to decrease or increase pressure, etc.). You can also stop the treatment at any time.I hereby consent to the rendering of evaluations, treatments and/or services as communicated by the Massage Therapist. My consent is voluntary, and I intend this consent to cover the entire course of assessment/treatment commencing on the date indicated below. I understand that I may ask questions at any time regarding the assessment and treatment and that this consent may be withdrawn at any time. Patient (or Guardian) Name(Required) First Last Patient (or Guardian) Signature(Required)Date(Required) Month Day Year NameThis field is for validation purposes and should be left unchanged.
