Hot Stone Massage Release Form-Bellezzaangels.com

Hot Stone Massage Release Form

Hot Stone Massage Contraindications

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 which may make hot stone massage contraindicated or may require your therapist/practitioner to alter the massage.

Pregnancy
Blood clot(s)
Diabetes
Neuropathy
Inflammatory skin conditions
Autoimmune condition (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 opportunity for any questions.

I have disclosed any and all health risk factors.

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

I acknowledge I been 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 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).

Date

Your Signature