I am voluntary requesting a Breast/Chest massage and I hereby authorize to perform a Breast/Chest massage by a Licensed Lactation Counselor.
- I certify I am over the age of 18
- I fully understand the nature and purpose of this treatment.
- I understand that this written Consent and release form will act as a record of my the understanding of the treatment and my desire for my massage therapist to provide a breast and chest massage treatment.
- I understand that if I have any questions either from my discussion or while completing this form it is important that I talked to the therapies for clarification prior to signing.
- During the discussion my therapist explain the benefits waste and potential side effect of breast massage.
- I have been informed of the areas to be treated positioning and how I will be drop (covered)during the massage session.
- I have had the opportunity to ask questions about the above information and I am aware I can ask questions at any time if I feel uncomfortable for any reason before or during the breast and chest massage I will ask the therapist to seize the treatment and continue massaging other areas or to end the session completely.
- I understand that I may modify or withdraw my consent for this treatment or the entire massage, at any time during this or any other treatment.
- I understand that the therapist will work with his or her hand directly on my uncovered breast or chest while performing this massage.
- I understand that there is no implied or stated guarantee of the success of the effectiveness of the individual techniques or series of appointments.
- If I experience pain or discomfort during the session I will immediately inform my therapist so that pressure and strokes can be adjusted to my level of comfort. I will not hold my therapist responsible for any pain or discomfort experienced during or after the session.
- I understand that the service offered to they are not a substitute for medical care. Understand that my therapist is not qualify to perform spinal or skeletal adjustments diagnose prescribe or treat physical or mental illness.
- I affirm that I have notified my therapist of all known medical condition and injuries.
- I agree to inform the therapist of any changes in my health and medical condition. Understand that there shall be no liability on the therapist part should I forget to do so.
- I understand that massage is entirely therapeutic and non-sexual in nature.
- I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. and i will be liable for payment of the schedule appointment.
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Submission is equal to full consent and is equivalent to patient’s signature.
By signing this released I hereby waive and release my therapist from any and all liability, past, present, and future relating to massage therapy and bodywork.