Hot Stone Massage Consent Form
Client Information
Name:
Date:
Phone Number:
Email:
Health Information
Do you have any of the following? If yes, please specify.
Diabetes
Skin Conditions
Poor Circulation
Recent Surgery
Pregnancy
Blood Clots
Varicose Veins
Other
If any, please provide details:
Consent & Acknowledgement
I understand the nature of Hot Stone Massage and the risks involved.
I agree to inform the therapist of any discomfort during the session.
I confirm that the above information is accurate to the best of my knowledge.
Additional Notes:
Client Signature:
Date:
Therapist Signature:
Date: