Massage Information & Consent

First Name

Last Name

Address

City

State

Zip

Email

Cell Phone

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Medical History

Check all that apply:

  • I've had a professional massage
  • Pregnant
  • Lactating
  • Hypo/Hyper Thyroid
  • Heart disease / pacemaker
  • Diabetes / Epilepsy / Hemophilia
  • High / Low Blood Pressure
  • Cancer
  • HIV
  • Immune Disorder
  • Herpes
  • Open Wounds / Lesions
  • Infections
  • Carpal Tunnel Syndrome
  • Regular Exercise
  • Skin Conditions
  • Sciatica
  • Tendonitis
  • Fibromyalgia
  • Plantar Fasciitis
  • Headache / Migraines
  • Kidney Disease
  • Infectious Condition
  • Spinal Injuries
  • Bulging Disc
  • Asthma / Lung Conditions
  • Varicose Veins
  • Arthritis
  • Motor Vehicle Accident
  • Whiplash
  • Surgery
  • Blood Clots / Aneurysms
  • Depression
  • Chronic Pain
  • Chronic Illness
  • Athlete's Foot
  • Sleeping Disorder

Please list any other medications you're currently taking:

Please list any known allergies or sensitivities:

Please list any other illnesses/conditions you are currently being treated for by a medical professional, or any other medical condition we should be aware of (fever, common cold, infection, etc.):

Do you have any special needs or areas that require special attention? If yes, please specify:

Policy Disclosures

Please check each policy to state that you read and understand the policy:

I understand that any missed/cancelled appointments without 24 hour notice will result in charge of the full amount of the service and will be charged to the credit card I have provided on file (non-members), gift card, or my Valley membership (members only).

I have read and understand the above

I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically

I have read and understand the above

I take it upon myself to keep the therapist updated on my physical health

I have read and understand the above

I understand that if I have any concerns, I will address these with my massage therapist.

I have read and understand the above

Informed Consent

Please sign to state that you read and understand the policy

I give permission to my massage therapist to perform the procedures we have discussed. I agree to hold harmless The V Spa, its employees and agents for any liability that may result from this treatment and/or for any of my conditions that were present but not disclosed at the time of this service. I have accurately answered the questions above, including all known allergies, prescription drugs, conditions, or products I am currently ingesting or using topically. I understand my massage therapist will take every precaution to minimize or eliminate negative reactions as much as possible. I understand that massage therapists do not diagnose illness, disease, or other medical, physical, or emotional disorders or prescribe medical treatment or pharmaceuticals. It has been made clear to me that massage is not a substitute for medical examination or diagnosis and that I am responsible for consulting a qualified physician for any physical ailment I might have. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I also affirm that I am at least 18 years of age, or have parental consent to receive my massage today (if under 18, parent or guardian signature must be present).

I have read and understand the above

Please check all consent and disclosure checkboxes.

Your form has been successfully submitted. Thank you!

Adult Signature:

Sign for Child: