The information requested below will assist us in treating you safely. Feel free to ask any questions about the information being requested. Please note
that all information provided below will be kept confidentially unless allowed or required by law. Your written permission will be required to release any
information. Clinical notes for your appointment entered by your Therapist will be available for our other therapists in order to ensure you are provided
with the appropriate treatment at each appointment.

Cardiovascular:

Head/Neck:

Respiratory

Consent: By signing below, I acknowledge that I understand and accept the Massage Experts Privacy Policy, which can be found
at https://www.massageexperts.ca/privacy-policy/

It is my choice to receive massage services. If at any time, for any reason, I feel uncomfortable I can request my service to end, and the provider will end the session. Because massage/bodywork, and other treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, or answered all questions asked of me honestly. I will update Massage Experts of any changes to my health status. I understand that Massage Therapists do not diagnose illness. disease. or physical or mental disorders. nor do they prescribe medical treatments, pharmaceuticals, or perform spinal manipulations or skeletal adjustments and that nothing said in the course of the session given should be construed as such. I acknowledge that these treatments are not a substitute for medical examination or diagnosis, and that it is recommended I see a primary health care provider for that service. If I experience any pain or discomfort during the session, I will immediately inform the Massage Therapist so that the service may be adjusted to my level of comfort or discontinued. I further understand that I am paying for a treatment and not a result and that there will be no returns, refunds or exchanges.

I understand that MASSAGE EXPERTS reserves the right to refuse to administer services at their sole discretion. I have read and fully understand this form in its entirety. If at any time there are changes in the information given, or in my condition, I will notify my service provider, and update this form before receiving additional services. I have read and fully understand this form in its entirety. I hereby release the Massage Therapists, MASSAGE EXPERTS and their insurers, and their respective officers, directors, stockholders, successors, employees, franchisor and agents from all liability of any nature whatsoever, whether past, present, or future, for injury or damage which may occur to myself or my family as a result of my receiving massage therapy.

My signature below affirms that I have read, agree to the foregoing and the information I have provided is accurate and true.

Consent to treatment of minor: By my signature below, I authorize MASSAGE EXPERTS to administer massage therapy to my minor child or dependent, named on this form, as they deem necessary or proper.