It is my choice to receive massage therapy and I give my consent to receive treatment. I have completed this form to the best of my knowledge and will inform the massage therapist of any change in my physical health.

I understand that a massage therapist cannot diagnose illness, disease, or any other medical, mental, or emotional disorder. Nor do they prescribe medical treatment, pharmaceuticals, or perform spinal thrust manipulations.

I realize that the treatment is being given for the well being of my body, mind and spirit. This includes stress reduction, relief from muscular tension, spasm or pain, also for increasing circulation or energy flow. I agree to communicate with my practitioner any time I feel like my well being is compromised.

I acknowledge that massage is not a substitute for medical examination or diagnosis; I am responsible for consulting a qualified physician for any physical ailments that I have.

I understand that massage therapy is a therapeutic health aide and is non-sexual. At anytime should myself or the therapist become uncomfortable the session maybe terminated. Should the session be terminated due to my actions, I understand I will be held responsible for full payment.

I understand Three Little Bears Pediatric and Family Massage, LLC is a Tobacco, Substance and Alcohol Free Facility. I will refrain from smoking, drinking or otherwise engaging in substance use prior to my scheduled appointment. I understand that if I fail to do so, the therapist has the right to cancel my session at my cost. I understand that this for my safety and others around me. I understand If I fail to adhere to the Tobacco, Substance and Alcohol free policy multiple times this may result in my termination as a client.

I have read and agree with the above statements.