CONSENT FOR MASSAGE THERAPY & WAIVER OF LIABILITY

Please read and initial each statement. By initialing each statement, you have agreed to the terms stated. When finished, please sign your name below.

1. I acknowledge and agree that I have provided the Therapist and Hunters Run Country Club with my complete and accurate health information and will not hold them responsible for any injury or damages resulting from incomplete or inaccurate disclosure of such information. The information I have provided is true and complete to the best of my knowledge.
2. I agree to inform the Therapist of any unusual sensation, pain or discomfort during my session, so that the application of pressure may be adjusted to my level of comfort. Also, I understand that I may terminate the session at any point in time if I feel uncomfortable with the course of treatment.
3. I acknowledge that the Therapist is not a physician and does not diagnose illness or disease or any other skin condition, physical or mental disorder. I further acknowledge that the massage therapy I am receiving is at my own risk and is designed to be an ancillary health aid and is not suitable for primary medical treatment of any condition.
4. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment.
5. I hereby assume full responsibility for receipt of the massage therapy, and release and discharge Hunters Run Country Club and the Therapist from any and all claims, liabilities, damages, actions, or causes of action arising from the service received hereunder, including, without limitation, any damages arising from acts of unintentional or passive negligence on the part of the therapist, to the fullest extent allowed by the law.
6. By signing this Consent for Therapy and Waiver of Liability, I understand and agree that this instrument will apply to and govern the current and all future therapy sessions performed by the Therapist. If for any reason there is a change in my health, it is my responsibility to notify the therapist at any future appointments, before receiving treatment, and I acknowledge I will need to fill out a new Consent and Waiver of liability Form.
7. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law.
8. I authorize my therapist to release or obtain information pertaining to my condition(s) and/or treatment to/from my other caregivers or third party payers.
9. I have read and understand the foregoing and I have had the opportunity to question the contents of this form. By signing this instrument, I confirm my consent to all treatments and intend this consent to cover the treatments discussed with me and such additional treatments as proposed by my Therapist from time to time, to deal with my skin care needs and for which I have sought treatment. I understand that at any time I may withdraw my consent and the service will be stopped.
10.Please read and agree to each statement below. By clicking the “Agree to All” button, you have agreed to the terms stated.

Member/Guest (or parent/legal guardian)