Hot Stone Release Form

Please fill out the form below at least 24 hours before your appointment.

Hot Stone Massage Release Form

Hot Stone Massage Contradications

Hot Stone Massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions.

Pregnancy
Diabetes
Inflammatory skin conditions
Open wounds or sores
Hypotension or Hypertension
Cancer (with or without treatments)
Varicose veins
Under the influence of drugs or alcohol
Blood clot(s)
Neuropathy
Autoimmune condition (MS, Lupus, RA, etc.)
Peripheral vascular disease
Heat sensitivity
Compromised immune system
Edema or Lymphedema
Cardiovascular disease

Client's Release

I have read and understood the aforementioned conditions that make hot stone massage contraindicated. The massage therapist/practitioner has discussed this information with me and provided me with the opportunity to ask questions. I have disclosed any and all risk factors.

Please check the following that applies to you.

I understand the information contained in this form and I do not have any of the above following conditions.

Conditions?

My condition(s) of ________________________________ is/are listed above and therefore make(s) hot stone massage contraindicated. 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 directly or indirectly from my receiving hot stone massage.

I understand that I will be receiving hot stone massage as an adjunct for of healthcare only and that this is not to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during any treatment(s).

Signature

Date