, do hereby request and give permission to receive treatment from Sage Acupuncture LLC, and any of its affiliates.
Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session. Informed written consent must be provided by parent or legal guardian for any client under the age of 17.
Draping of the breasts, genital area, and gluteal cleavage will be used at all times during the session for all clients. If the client is uncomfortable for any reason, the client may ask the licensee to end the massage, and the licensee will end the session. The licensee also has a right to end the session if uncomfortable for any reason.
I understand that I will be receiving massage therapy for the sole purpose of stress reduction, relief from muscle tension or spasm, and/or increasing circulation. If I experience any pain or discomfort during a session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I understand that the massage therapist does not diagnose illness, and, as such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor do they perform any spinal manipulations. I am aware that this massage is not a substitute for medical examination/diagnosis and that nothing said or done in the course of a session should be construed as such. Additionally, it is recommended that I see a physician for any ailment that I might have. I understand and agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy I HEREBY HOLD HARMLESS AND INDEMNIFY the therapists, their principals, and agents from all claims and liability whatsoever.
Policies & Procedures:
Appointment Reminders and Follow Up Communication
We may use or disclose your health information to provide you with appointment reminders and follow up communication via phone, voicemail, email or letter.
I have reviewed Sage Acupuncture LLC’s notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document upon request.
- Payment is due at the time of service. We accept cash, checks, and most major credit cards.
- Your appointment time is reserved specifically for you. In the event of a missed appointment or an appointment canceled, for any reason, with less than 24 hours notice you will be charged a fee.
- A fee will be charged for returned checks.
- We reserve the right to change our fee scale without notice.
Any photographs, audio or video recordings of myself or my family that I participate in or submit to Sage Acupuncture LLC, may be used for any purpose without compensation in perpetuity.
I have completed this form to the best of my knowledge. I have read and understood the Informed Consent and Privacy & Procedures information. By signing below I agree to a course of treatment and intend this consent form
to cover the entire course of treatment for my present condition as well as any future condition(s) for which I seek treatment with this practice.