Informed Consent for Massage & Cupping Waiver 

1. I understand that the practitioner is not a medical doctor and does not diagnose illness,  disease, or any physical or mental disorder. I acknowledge that massage and alternative holistic  therapies are not substitutes for medical treatment and that Brealyn Raine, LMT, “the company”  recommends I see a primary healthcare provider for that service. I understand that it is my  responsibility to communicate with my therapist is I have concerns or questions about my  session. I do not have any injuries or conditions that would prevent me from receiving a  massage, nor have I been told by a health care provider that I should not receive massage or  alternative therapies.  

2. I understand that massage therapy and bodywork services are a therapeutic health aid and are  non-sexual. I understand the practitioner reserves the right to end a therapy session in the case  of sexual innuendo or advances from the client. I also understand that any illicit or sexually  suggestive remarks or advances made by me will result in immediate termination of the  massage, and I will be liable for full payment of the scheduled session. 


3. Any information exchanged during a massage or bodywork session is confidential and is only  used to provide me with the best health care services available. I understand that my  practitioner will ask me questions about my health and physical condition and that I am  obligated to answer truthfully and honestly about my health history in full detail.  

4. I understand that my feedback is essential in my treatment, and that if I experience any unusual  discomfort and/or pain during my massage session, it is my responsibility to inform the  therapist in order to enable the therapist to adjust the pressure or technique being used.  

5. The therapist reserves the right to decline, discontinue, or restrict services based on any  provided information that may indicate that massage therapy would put my health or the  therapist’s health at risk.  

6. I acknowledge that I am responsible to be on time for my appointments and that the therapist is  not under any obligation to extend my therapy session. I also agree that I am responsible to pay  for the full time I have booked with the therapist if I am late. I understand that my appointment  time is reserved for me only. If I miss an appointment or am unable to give twenty four (24)  hours’ notice when I need to change or cancel my appointment, I agree to pay the business in  full for the booked appointment time.   

7. I understand that massage therapy and body work are for the purposes of stress reduction relief  from muscular tension and spasm, general relaxation and improvement of circulation and  energy flow.  

8. I understand that the practitioner does not prescribe medical treatment of pharmaceuticals, nor  does she perform any spinal manipulations.  

9. I understand that service offered today, and in the future, are not a substitute for medical care  and that any information provided to me by the practitioner is purely for education purposes  and is not diagnostically prescriptive in nature.   

10. I have stated all of my known medical conditions on the Client Intake form. I have consulted a  medical doctor or licensed medical health care practitioner regarding any checked or described  conditions.  

11. I understand that it is solely my responsibility to keep the therapist updated on any changes in  my physical health and I further understand that company and the therapist shall not be liable  for any purpose and for any reason whatsoever, should I fail to do the needful as per this  paragraph.  

12. I have reviewed this form in its entirety and I have discussed all my concerns regarding my  treatment with my therapist.  

13. I understand that all treatments at this facility are therapeutic in nature. I agree to notify the  therapist of any physical discomfort or draping issues during the session.  

14. This facility has provided me with information on the ACE Massage Cupping™ technique. If I  choose to experience this therapy in my treatment, I understand the effects and after-care  recommendations. It has been explained to me that there is the possibility of a skin  discoloration, or “cup kiss,” appearing as tissue is released. I am aware that a “cup kiss” is not a  bruise and that it will dissipate within a few hours to a few days.  

Client​:   By signing this ​ “Informed Consent for Massage & Cupping Waiver”​ I consent to receive therapy at  Brealyn Raine, LMT ​ and hereby agree to all policies of ​ Brealyn Raine, LMT ​ , and waive and release   Brealyn Raine, LMT ​ and it’s practitioner(s) from past, present, and future liability, loss, cost, claim or  damage whatsoever which may be imposed upon the business relating to massage therapy and  bodywork; including but not limited to reflexology, acupressure, polarity therapy, energy therapies, all  forms of kinesiology, aromatherapy, myofascial release therapy, trigger point therapy, stretching  therapy, among others. I further undertake to indemnify and hold ​ Brealyn Raine, LMT ​ harmless from  any incident(s) arising from my use of the ​ Brealyn Raine, LMT ​ ’s services.      

I agree to and acknowledge the foregoing on this day of ___________/_____________/_____________    

Signature, Printed Name  _____________________________________________________________________________________________________       

Parent/Guardian Waiver For Minors:  If the client is less than 18 years old, the Client’s parent and natural guardian hereby represents that  he/she is, in fact, acting in that capacity, has consented to his/her child or ward’s availing of the services  of ​ Brealyn R aine, L M T, ​ and has agreed individually and on behalf of the child or ward, to the terms of  this “Informed COnsent and Waiver”. The undersigned parent or guardian further agrees to save and  hold harmless and indemnify ​ Brealyn R aine, L M T ​ from all loss cost, claim, or damage whatsoever  which may be imposed upon ​ Brealyn R aine, L M T ​ relating to massage therapy and bodywork; including  but not limited to reflexology, acupressure, polarity therapy, energy therapies, all forms of kinesiology,  aromatherapy, myofascial release therapy, trigger point therapy, stretching therapy, among others, on  behalf of the Client and all of the Client’s parents or legal guardians.  

I agree to and acknowledge the foregoing on this day of ___________/_____________/_____________  _____________________________________________________________________________________________________  Parent or Legal Guardian Signature, Printed Name 



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