Massage Therapy Consent & Waiver Form

 hereby agree that by signing this document, I consent to waive certain legal rights including but not limited to the right to sue the following party, and, if applicable, its owners, therapists, and representatives from any physical, material, tangible or intangible loss of damage that may happen to me during my participation in any if the massage services(hereinafter, “Massage Services”).

(Massage Therapist Name)
3418 W 84TH Street, Suite 104, Hialeah, FL 33018
305.395.7007
info@holisticelite.com

I am voluntarily receiving Massage Services from the Massage Service Provider listed above.
The following is the identifying and contact information for me, the client(“Client”):

The contact information of my emergency individual is al follows:

Treatment Questions

Choose your pizza toppings

List any health disorders you have or any areas which may be sensitive to physical touch. Examples of such disorders (not limited to) the following is not to be considered a comprehensive list but you may write below those applicable: bone or joint disease, allergies, tendinitis, rashes, Bursitis, athletes foot, broken/fractured bones, Constipation, neck pain, shoulder pain, arm pain, low back pain, hip pain, leg pain, headaches, head injuries, herpes, shingles, arthritis, diverticulitis, any irritable bowel syndrome, fatigue, sleep disorders, spasms, depression, anxiety, cancer, tumors, PMS/PMDD, endometriosis, varicose veins, diabetes, infectious disease, high blood pressure, low blood pressure, eating disorders, easy bruising, blood clots, lymphoedema, sinus problems, respiratory difficulties or conditions, heart disease, asthma, drug/alcohol addictions, nicotine addictions, thyroid disorders, adrenal disorders fibromyalgia, or any chronic pain:

Financial notice: You are required to give at least 24 hours notice in the event that an appointment needs to be cancelled. If 24 hours notice is not received the following will apply: $35.00 fee will be assessed for ALL missed appointments not canceled.

Late Arrivals: If you arrive late to your appointment, you risk having your time shortened to accommodate all scheduled clients. When you arrive, the massage service provider will a certain whether a late start is possible. A late start may not be possible if you have arrived too late or if the massage service provider finds any reason to cancel the appointment. Regardless of the outcome or time, you will be responsible for the full cost of the session. Therefore, please do not arrive late.

My initials below indicate that I agree with and understand the following:

 It is my responsibility to consult a physician before participating in these or any massage services and I affirm that I have no medical conditions that will restrict me from participating in any of the massage services.

 I agree to hold the massage services provider, and if applicable, its owners, therapists, representatives, and facilities harmless from any damage, whether tangible or intangible, that may happen to me will participating in the massage service.

 I agree that the massage service provider offers the massage service with no guarantee of results. I agree that any results that occur, whether positive or negative, are the effects of my own personal choice.

 I agree that participating in the massage services is not a replacement for actual medical care, and that if I do experience medical issues, I will contact my doctor immediately.

 I agree and verify that all of the information that I have given the massage service provider and its representative is accurate, up to date, and without the omission of any known medical issues.

 I agree and verify that if I have omitted any necessary personal information whether knowingly or unknowingly, I will hold the massage service provider harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions.

 I agreed to keep the massage services provider apprised of any changes or upcoming changes concerning my physical health and personal information.

 I understand and agree that it is my responsibility to let the massage service provider know if I find myself in any pain or discomfort before, after, or during the massage services.

 I understand and agree that the massage services are not sexual in nature and any sexual innuendo, sexual or suggestive comments, or inappropriate touching will not be tolerated and will be cause for immediate termination of the session as well as my getting fired as a client. For privacy, blankets and draping will be used throughout the massage service session.

 If I do require medical treatment or attention while or after participating in them massage services, I agree that the medical costs are mine and mine alone and hold the massage service provider blameless from any charges, fees, or costs that my conditions may incur.

This massage therapy consent and waiver will bind and be enforceable against me and all my personal representatives. I agree that this massage therapy consent and waiver should be enforceable to the fullest extent of the law, and if any portion is held invalid the remainder should continue in full legal force and effect. I specifically acknowledge and agree that this document is not intended to be a general release, which will be limited under some state and local laws. The massage therapy consent and waiver shall be construed and interpreted as broadly as possible in the applicable jurisdiction.


ASSUMPTION OF RISK. I understand and am aware that my participation in the massage services involves risks. These risks may lead to tangible or intangible harm, and I agree that they may result not only from my own actions but also from the actions of others. With the knowledge and understanding of the risks, I choose, of my own will and volition, to continue participating in the massage services.


COVENANT NOT TO USE. I will not start any lawsuit or other court action against the massage services provider, or, if applicable, Facility, nor will I join any such proceeding including any claim for money damages. I acknowledge and agreed that I am entering a covenant not to sue the massage services provider in any capacity, including to hold the massage services provider liable for any injury, lost, or damage sustained by me or my property, even if it is due to the massage services provider’s negligence or omission. I also waive the right of any of my insurers’ to make any such claims.


INDEMNIFICATION: I agreed to defend and indemnify the massage services provider and any of its affiliates (if applicable) an hold them harmless against any and all legal claims and demands, including reasonable attorney’s fees, which may arise from or relate to my use or misuse of the massage services or my conduct or actions. I agree that the massage services provider shall be able to select its own legal counsel and may participate in its own defense, if desired.


REPRESENTATION: I am over 18 years of age, and am medically and physically able to participate in the massage services.


GOVERNING LAW: This massage therapy consent and waiver shall be governed by and construed in accordance with the internal laws of Florida without giving effect to any choice or conflict of law provision or rule. Each party irrecoverably submit to the exclusive jurisdiction and venue of the federal and state courts located in the following County in any legal suit, action, or preceding arising out of or based upon this massage therapy consent and waiver: Miami-Dade County.

I have read the above massage therapy consent and waiver fully and I understand and agree to its contents. I understand and agree that by signing this massage therapy consent and waiver I forfeit any right, claim, or ability to hold the massage services provider or its affiliates responsible for any tangible or intangible damages, loss of property, or loss of life that may occur during or after my use of the facility and participation in the massage services.