INFORMED CONSENT TO MASSAGE THERAPY TREATMENT

I attest that the information I have provided is true and complete to the best of my knowledge. I understand the information I have provided on this form is confidential and will not be released without my written consent. I consent to therapeutic massage treatment by Cove Massage Therapy. I also understand that I am responsible for any charges incurred in the course of my treatment. I understand that Cove Massage Therapy is providing massage therapy services within their scope of practice. I hereby consent for Cove Massage Therapy to treat me with massage therapy for the above noted purposes including such assessments, examinations and techniques, which may be recommended, by Cove Massage Therapy. I acknowledge that Cove Massage Therapy is not a physician and does not diagnose illness, disease, or any other physical or mental disorder. I clearly understand that massage therapy is not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment, there can be risks and those risks have been explained to me and I assume those risks. I acknowledge and understand that Cove Massage Therapy must be fully aware of my existing medical conditions. I have completed my medical history form as provided by Cove Massage Therapy and disclosed to the therapist all of those medical conditions affecting me. It is my responsibility to keep Cove Massage Therapy updated on my medical history. The information I have provided is true and complete to the best of my knowledge. I authorise Cove Massage Therapy to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third party payers, only when necessary and only with a prior verbal request. I have read the above noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by Cove Massage Therapy from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time, I may withdraw my consent and treatment will be stopped.