Majestic Thai Massage

Client Information

Full legal name *

Date *

Address

Phone number *

Email address

I am under the age of 17.

Parent or guardian name *

The parent or guardian gives written consent for massage therapy.

Health Information

Please select every condition that applies.

Pregnancy due date

Please explain any condition selected above

Other medical conditions the therapist should know about

Current medications

Requested Massage and Body Areas

Requested massage type *

Other requested massage

Areas of pain or tension

Specific body areas the client requests be avoided *

Required Statements and Client Acknowledgements

Massage therapy is not a substitute for medical examination or diagnosis. The massage therapist does not prescribe medical treatment or medication and does not perform spinal adjustments. I understand that serious medical conditions may require written approval from a physician before service.

The licensee shall drape the breasts of all female clients. Breast massage of a female client will not be performed unless the client provides written consent before each session involving breast massage.

Draping of the genital area and gluteal cleavage will be used at all times during the massage session for every client.

The licensee must immediately end the massage session if the client initiates verbal or physical contact that is sexual in nature.

If the client is uncomfortable for any reason, the client may ask the licensee to end the massage and the licensee will end the session. The licensee may also end the massage session if the licensee feels uncomfortable for any reason.

Client Signature

Typed legal name *

Sign below using a finger, stylus, or mouse *

Massage Therapy Session Consultation

Client Information

Health Information

Requested Massage and Body Areas

Required Statements and Client Acknowledgements

Client Signature