Sensitive Area Agreement

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When the treatment of sensitive areas is indicated during the course of a massage therapy treatment and/ or treatment plan, it is important that you, the client, fully understand the nature and purpose of this treatment.

In addition to our discussion about the treatment and/ or treatment plan, this written consent form will act as a record of that discussion. If you have any questions, either during our discussion or while completing this form, please do not hesitate to ask.

Email *

Full Name *

Phone Number *

Date of Birth *

YYYY

The areas I consent to receiving bodywork services *

Breast(s)

Upper Medial Thigh/Groin (adductor muscles/attachments)

Pubic Musculature

Coccyx Musculature

Other

Required

We may require a referral or prescription from your doctor. Have you received written authorization for the treatment of this area from your doctor? *

Yes

Unsure

Not yet, but I will prior to my first appointment.

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