Hot Stone Therapy Release Form

First Name

Last Name

Phone

Birthday

Address

Occupation

How often do you exercise?

Please list any skin or health conditions you are experiencing

A hot stone massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions. You must inform your massage therapist/practitioner if you have any of the following conditions that may make hot stone massage contraindicated or require your therapist/practitioner to alter the massage.

Pregnancy
Blood clot(s)
Diabetes
Neuropathy
Inflammatory skin conditions
Autoimmune conditions (MS, Lupus, RA, etc.)
Open wounds or sores
Peripheral vascular disease
Hypotension or Hypertension
Heat sensitivity
Cancer (with or without treatment)
Compromised immune system
Varicose veins
Edema or Lymphedema
Under the influence of drugs or alcohol
Cardiovascular disease

I have read and understand the aforementioned conditions which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided an opportunity for any questions. I have disclosed any and all health risk factors. Please check the following that applies to you.

I understand the information contained on this form and confirm that I do not have any of the above conditions.

My condition(s) is/are listed above and therefore make(s) hot stone massage contraindicated. Given this knowledge I hereby give my full consent to receive hot stone massage and take full responsibility of any side effects or harm that may come from my receiving hot stone massage.

I understand the information contained on this form and confirm that I do not have any of the above conditions.

I understand that I will be receiving hot stone massage as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during my treatment(s).

Your Signature

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