Informed Consent Esign Form

Welcome to the Therapeutic Massage Center of Middleton

Massage Defined

Massage can be defined as structured, professional touch. Massage techniques manually manipulate the muscles, tendons, and fascia of the body to promote health and wellness. Benefits of massage include stress reduction, circulation enhancement, increased relaxation, and relief from muscular tension, soreness, and pain. Limitations of Massage Massage therapists do not diagnose medical diseases or musculoskeletal conditions and massage is not a substitute for medical examination and treatment. Massage therapists do not prescribe herbs or drugs, including aspirin or ibuprofen, or medical treatments. They do not perform spinal adjustments and they cannot counsel clients about emotional issues as would be provided by a mental health professional. If you experience symptoms that lead you to believe you may have a medical condition, it is recommended that you visit a physician for diagnosis and treatment. Adverse Reactions to Massage Massage may lead to adverse reactions in certain situations or when used with certain conditions or medications. The massage therapist will evaluate your health-history intake and ask you questions to make sure it is safe for you to receive massage. In the event the massage therapist is uncertain that massage will benefit you, he or she may ask you to provide a note from your physician stating that it is safe for you to receive massage. Please provide complete details of medical conditions and medications to your massage therapist during the health-intake interview. Failure to inform the massage therapist of all medical conditions and medications may place you at increased risk for adverse reaction.

The Therapeutic Massage Center of Middleton and You

Therapist Training and Experience All of the massage therapists working at the Therapeutic Massage Center of Middleton have completed a minimum of 500 hours of massage training from a state-approved school and passed the state licensing requirements. Therapists at the Therapeutic Massage Center of Middleton are knowledgeable in Swedish massage, deep-tissue and myofascial release techniques, as well as a wide array of massage techniques depending on the massage therapist. The massage therapist that you will be working with will determine what style of massage is best suited to your individual needs. Business Policies and Practices You may book a 30-minute, 60-minute, 90-minute, or 120-minute long session. The Therapeutic Massage Center of Middleton accepts cash, personal checks, and all major credit cards. We do not bill insurance companies for services. Please plan to arrive 10 minutes early to your appointment to allow for your individual intake session before the massage begins. The first session usually requires a longer health intake process, so new clients should arrive 15 minutes early on their initial visit.

Clients arriving late will be charged for the full session and the session will end promptly at the scheduled time. Clients must cancel sessions with 24 hours notice or pay 100% of their scheduled appointment cost. Returned checks will be charged a $20 processing fee. Business hours are Monday-Friday from 9 am until 7 pm and Saturdays from 10 am until 3 pm. Children and teens are welcome, but and adult guardian must be present with the minor in the treatment room for the entire session. Expectations and Rights The client is expected to demonstrate good hygiene and not use illegal drugs or alcohol before the session (the use of drugs and alcohol make it unsafe for a client to receive massage). Clients and therapists are expected to refrain from any behavior of a sexual nature, including sexual jokes, nicknames, or immodest conduct. Sexual behavior from the therapist toward a client is grounds for therapist termination and may lead to a formal compliant filed with the state board of massage. This may lead to the loss of the therapist’s license. Sexual behavior from the client toward the therapist is inappropriate and will lead to the termination of the session and refusal of further service. The client has a right to prompt, professional service in an environment that is clean, private, and safe. Client information is not shared with any members of the public or other health-care providers unless the client releases the information in writing. A court of law may order the client’s health-care records released to the court as part of a legal proceeding. Therapists are obligated to report information about the abuse of a child, elderly person, or mentally or physically challenged person in the even that such information is related during the session. Therapists are obligated to report threats of self-harm, or threats that the client plans to harm another person, to authorities. The client has the right to end the session at any time should they feel dissatisfied or uncomfortable with the session in any way. Clients who are dissatisfied with a therapist are encouraged to contact the clinic owner. Formal complaints can be filed with the state on the Wisconsin Board of Massage website.

Your Massage Session

After you complete the health intake form, the therapist will take you to a private treatment room, review the form with you, and discuss your goals for the session. The therapist will customize the massage to meet your specific needs within the limits of his or her training and scope of practice. The therapist will then leave the room while you undress and position yourself under the sheet on the massage table. Only the area being massaged at the time is undraped as the session proceeds. The breast, genitals, and buttocks are never undraped during a session, and every effort is made to respect and protect both the client and the therapist’s modesty. You may leave on your underclothing if you prefer. While the therapist will ask you a few questions-for instance, about the comfort of the stroke pressure, room temperature, or comfort of the table-and you should let the therapist know immediately if you are not comfortable, other conversation during the session is generally discouraged. Silence allows you to relax fully and enjoy the session.

Client’s Declaration of Informed Consent

I , have read and understand the disclosures, policies, and procedures of the Therapeutic Massage Center of Middleton, and I would like to receive a massage session. I understand the benefits and limits of massage therapy and understand massage may cause adverse reactions in certain situations. If I experience any discomfort during the session, I will immediately inform my therapist so they can modify the massage strokes. I understand massage therapists do not diagnose diseases or conditions, prescribe medications or treatments, or perform spinal adjustments. I recognize massage is not a substitute for medical treatment and should I need medical treatment, I will seek out the appropriate health-care professional (physician, chiropractor, etc.). I understand that it is my responsibility to keep the massage therapist informed of changes in my health status, diagnosed medical conditions, and medication. I understand that failure to inform the therapist of these changes may place me (or my child or dependent) at greater risk of adverse reactions to massage. I release the massage therapist of any liability if I fail to disclose the appropriate health-related information.

May 30, 2023

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Signature Certificate
Document name: Informed Consent Esign Form
lock iconUnique Document ID: b09a771ab999fe906f76ef3d481eac1423f969a9
Timestamp Audit
September 8, 2020 1:49 pm CDTInformed Consent Esign Form Uploaded by Carmela Wiese - IP
October 27, 2020 6:32 pm CDT Document owner has handed over this document to 2020-10-27 18:32:06 -