Emily Chapman, LMT | Consent Form – EB Chapman Enterprises

Please fill out the following consent form prior
to your first massage appointment with Emily.
We look forward to seeing you soon!

The information that I provided in the New Client Intake Form is true and accurate. *

Client Initials

I understand that massage therapy should not be construed for medical treatment and that I should see a physician for diagnosis of a treatment for any medical or physiological conditions. *

Client Initials

I will keep my practitioner informed of my concerns I have during the services. *

Client Initials

The New Client Intake Form and content are valid for the first appointment and every date after, unless I request a new document. *

Client Initials

I understand that the services I am scheduled for may include postural assistance and touch. I will inform my practitioner immediately if that touch is uncomfortable. *

Client Initials

I understand that all services rendered are therapeutic in nature and that sexual advances or remarks will terminate the session and that I will be liable for payment of the scheduled treatment, as well as refused to be seen in the future. *

Client Initials

Emily Chapman, LMT is not responsible for any and all claims including lost, damaged, or stolen personal belongings. *

Client Initials

If the client begins to feel discomfort during their service, the client may request to discontinue their service at any time. There will be no charge for the service. *

Client Initials

If the practitioner conducting the service feels the service is no longer reasonable to continue with the client, the service may be discontinued anytime. There will be no charge of service. *

Client Initials

If the client is pregnant, massage is recommended after the first trimester. If the client insists otherwise, the practitioner is not liable for any health concerns for the remainder of the pregnancy. *

Client Initials

If the client is under the influence of drugs or alcohol, it is best for the client's health not to receive a massage. If client fails to mention that they are under the influence, the practitioner is not liable for any injury endured after the client leaves. *

Client Initials

Clients under the age of 13 years old have to be accompanied by their legal guardian or parent. *

Client Initials

Please print your name *

First

Last

Signature *

Parent/Guardian Signature

If you are under the age of 18 years old, a parent of legal guardian must sign this consent form.

Please fill out the following consent form priorto your first massage appointment with Emily.We look forward to seeing you soon!

Please fill out the following consent form prior
to your first massage appointment with Emily.
We look forward to seeing you soon!