Participant Agreement    |  
Rights & A/V Waiver
Scope of Practice and Services  |

IMPORTANT: If YES to any question below, kindly discuss prior to the service with the therapist. 

A. Another treatment or service today?    D. Bruise, skin problem or cut?      G. Unclear of risk/ benefit of massage? 

B. Significant stressor or concern?             E. Protective of area of body?        H. Medication taken or cream used?

C. Inflammation, numb or coldness?         F. Bone or heart dysfunction?         I. Recent surgery or radiation?

 

I am voluntarily participating in the services entirely at my own risk. The risks may include, but are not limited to, those caused by terrain, facilities, temperature, weather, lack of hydration, condition of participants, equipment, vehicular traffic and actions of other participants, volunteers, spectators, officials and representatives of MTM. I am aware as is the case with any physical activity, the risk of injury is great, even serious or disabling, always present and cannot be entirely eliminated. Nonetheless, I assume all related risks, both known or unknown to me, may involve a test of my physical and mental limits and carry the potential for dynamic homeostasis. If I am pregnant, become pregnant, am post-natal, post-surgical, or otherwise in a questionable health status then my participation verifies that I have my physician's approval to participate as I alone have taken responsibility at my own risk. 

 

Services, including massage and yoga, are in no way a substitute for medical attention, examination, diagnosis, treatment, or care which is not recommended as safe under certain medical conditions. I affirm that a licensed physician has verified my good health and physical condition to participate. In addition, I will make MTM aware of any medical conditions, mental or physical limitations before participating in services; may include hands-on exercises, physical interaction, manual manipulation, verbal instruction or printed material provided related to massage therapy, manual manipulation of my body’ soft tissue, movement, stretching, anaerobic conditioning, aerobic conditioning, mental exercise training, physical exercises, suspension training, use of body manipulating equipment, yoga props, stretching devices, health material, spiritual guidance, or fitness related subjects.

 

In the event that I should require medical care or treatment, I am financially responsible for any and all costs incurred as a result of such diagnosis, treatment, or follow-up indefinitely. I am aware that I should carry my own health insurance. 

 

I do hereby further declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other reason that would prevent my participation or use of equipment or machinery because I have either had mental and physical examinations with a qualified medical provider’ consultation giving permission to participate in services OR that I have decided to participate in the activity and use of equipment without the approval of my physician and, either way, I hereby assume all responsibility for interactions with MTM, use of equipment, tools, or machinery.

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