Client Consent Form
Printed name of client _______________________________ Date ___________________
By my signature below, I acknowledge that I have agreed to receive one or more bodywork/reflexology sessions. I understand that:
- The therapist has not made any guarantees or promises regarding the results of this process upon me, and any relief of physical or emotional symptoms is coincidental to the process and is not a goal of the session.
- These sessions are not involved with the treatment of disease, illness or disorders of any kind, nor do they substitute for medical diagnosis or treatment when such attention is needed. Likewise, the practitioner does not diagnose or treat any illness, disease, or other physical or mental disorder of the person; and nothing said or done by the practitioner should be construed as such.
- It is necessary for the practitioner to touch and observe my body in order to conduct this process. I am aware that this work is performed directly on the skin with the use of lubricants, and that all areas of my body not being treated will remain draped. I give the practitioner full permission to work on my body in such a way.
- Reactions that can occur include, but are not limited to, the following:
Common reactions
Increased urination
Flatulence and more frequent bowel movements
Outbreak of sweat in the palms, feet or other body areas
Increased secretion in mucous membranes
Increased vaginal secretions and discharge
Disrupted sleep patterns
Tiredness
Less common reactions
Headaches
Dizziness
Emotional release, tendency to weep
Temporary outbreak of suppressed diseases
Aggravated skin conditions (pimples)
Chilliness
Inner shivering, chattering of the teeth, spasms
I may experience some or all of these reactions.
- In my role as client: it is my responsibility to:
- Arrive for sessions on time; notify the practitioner at least 24 hours in advance if I need to
change or cancel an appointment. Payment is required if 24-hour notice is not given.
- Provide information on my health status on the forms provided, and keep the practitioner updated as to
changes in my health status.
- Provide the practitioner with accurate and detailed feedback on their massage/reflexology work both during and
after the appointment.
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| Client's signature | | Phone number |
| ___________________________________________________________ | | _______________________________________ |
| Street address | | City, State, Zip |
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