Massage Therapy Consent Form

Massage Therapy Informed Consent
Massage therapy consists primarily of hands-on manipulation of the soft tissues of the body,
specifically, the muscles, connective tissue, tendons, ligaments and joints for the purpose of
optimizing health. RMTs use a variety of skills and techniques to provide the most appropriate
treatment for you according to their scope of practice and standards of practice. Generally, a massage treatment includes, but are
not limited to, Orthopedic Physical Assessment, Swedish Massage, Trigger Point Therapy, Myofascial Techniques, Joint Mobilizations, Hydrotherapy, Lymphatic Drainage and Home-care Exercise.
What to Expect in a Massage Appointment
After receiving your health history form, your massage therapist will perform a short interview and physical assessment and will
help to identify the underlying problem and make recommendations of how to proceed with a treatment that will optimize your
outcome and physical well-being. To get a clear picture of health it is very important to inform your RMT of any diseases or health
condition you are experiencing or suspect you are experiencing, as well as if you are pregnant. This is to avoid unforeseen
complications.
While in treatment you will be respectfully covered and only the area being directly massaged will be uncovered to allow for
massage treatment. Some techniques may even be administered while you are fully dressed. Your massage therapist will
communicate with you before and during your appointment to ensure your treatment is appropriate for your comfort level. If you
have questions regarding your treatment feel free to ask your RMT any time and know that you have the right to modify or STOP
your treatment at ANYTIME. Your RMT may offer exercises to do at home to further enhance your treatment and aid in recovery.
Side Effects and Risks of Massage Therapy
Like anything, there is the possibility of some risks and/or side effects with massage therapy. Some of these include but are not
limited to:

Aggravation of pre-existing conditions

Temporary soreness, tenderness or discomfort

Bruising

Redness or swelling
30 minutes
$50.00

Headache or light headed feeling
45 minutes
$69.00

Minor skin irritation and rash
60 minutes
$85.00
75 minutes
$95.00
90 minutes
$120.00
Fee Schedule
All fees for service are required at the time of service.
Gift Certificates are available.
All prices include HST
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Reiki (approx. 60 min)
$70.00
Aromatouch Technique (45 min)
$69.00
Aromatouch PLUS (60 min)
$95.00
Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4
W: www.greenbasehealth.com E: [email protected] T: 519-574-5151
Cancellation Policy
Time is a terrible thing to waste so in order to provide quality care in a professional and respectful way it is our policy that a
minimum of 24 hours notice is required for any cancelled or rescheduled appointment. This helps us to be better able to utilize
appointment availability to help others in need if you aren't able to make your scheduled appointment. You may contact us by
phone or email if you need to cancel or reschedule. A missed appointment or late cancellation (within 24 hours of scheduled
appointment) will be subject to a $30.00 fee at the discretion of the RMT. If you arrive late to an appointment you will be
responsible for the total cost of the scheduled appointment and be given the remaining time scheduled for treatment. If
scheduling allows, an effort will be made to offer you as much of the original treatment time as possible.
Privacy Policy
A record of your health services will be kept along with your health history form and this consent form. This file will be kept
confidential and will not be released to anyone unless so directed by you or your representative or is required by law. You may
review your file at any time and can request a copy for your records.
Motor Vehicle Accidents
If you have been in a motor vehicle accident and are claiming treatment through car insurance, please inform your therapist
immediately. Additional documentation and communication with your primary care provider is needed to initiate or continue with
treatment. Please note that any service fees not covered by your insurance company are your responsibility and must be paid
when services are rendered.
If you have any other questions regarding your treatment or about other services offered at Green Base Health please don’t
hesitate to ask.

I have read the above information and with this knowledge I voluntarily consent to the assessment, treatment and office
procedures outlined in the document.

I intend this consent to apply to all of my present and future massage therapy treatments at Green Base Health with
Robyn Ellis RMT and I understand that I am free to withdraw my consent at any time.

I understand that I am responsible for payment of services rendered according to the set fee schedule for massage therapy
and other related treatments or services. I also understand that I am responsible for missed/cancelled appointment fees.
Patient Signature: _________________________________
Patient Name: ____________________________________
Date: _____________________________
* If Patient is under the age of 18
Parent’s Name: __________________________________
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Green Base Health Consulting 22 Water St South, Kitchener ON N2G 4K4
W: www.greenbasehealth.com E: [email protected] T: 519-574-5151