LIVE RIGHT MASSAGE THERAPY CLINIC
INFORMED CONSENT TO MASSAGE THERAPY TREATMENT 
I understand that the Massage Therapist is providing massage therapy services within their scope of practice as defined by the 
Massage Therapist Association of Saskatchewan, Inc.  I hereby consent to my Massage Therapist to treat me with massage 
therapyfor the above noted purposes including such assessments, examinations and techniques, which may be
recommended by my Massage Therapist.I acknowledge that the Massage Therapist is not a physician and does not 
diagnose illness ordisease or any other physical or mental disorder. I clearly understand that massage therapy is
not a substitute for a medical examination. It is recommended that I attend my personal physician for any ailments 
that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as the 
the results of the treatment. I acknowledge assume those risks.

I acknowledge and understand that the Massage Therapist must be fully aware of my existing medical conditions.
I have completed my medical history form as provided by my Massage Therapist and have disclosed to the
Massage Therapist all of those medical conditions affecting me. It is my responsibility to keep my Massage 
Therapist updated on my medical history. The information I have provided is true and complete to the best of
my knowledge. 
I authorize my Massage Therapist to release or obtain information pertaining to my condition(s) and/or treatment 
to/from my other caregivers or third party payers.
I have read the above noted consent and I have had the opportunity to question the contents and my therapy. 
By signing this form, I confirm my consent and I have had the opportunity to question the contents and my therapy. 
By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed 
with me and such additional treatments as proposed by my Massage Therapist from time to time, to deal with 
my physical conditions and for which I have sought treatment. I understand that at any time I may withdraw my 
consent and treatment will be stopped.
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patient printed name                                           signature of patient/guardian
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massage therapist                                                 date signed