Policies & Authorization Policies & Authorization Name First Last Date MM slash DD slash YYYY Consent(Required) I agree to the policy.I also understand that the massage therapist/practitioner does not diagnose illnesses or injuries or prescribe medications. I have clearance from my physician to receive massage therapy. a. I understand the risks associated with massage therapy/neuro-stim MPS include but are not limited to: – Superficial bruising – Short-term muscle soreness Exacerbation of undiscovered injury – Detoxing – Soreness after stretching – Dehydration. (Drink plenty of water afterwards/ 50% of body weight in OZ.)Consent(Required) I agree to the policy.I give my permission to receive massage therapy, and therapeutic/medical massage is not a substitute for medical treatment or medication. Patient also will prepare and disrobe to their comfortability. Ex.(shorts/undergarments) or personal preference.Consent(Required) I agree to the policy.I therefore release the company/individual massage therapist from all liabilities concerning these injuries or treatment modalities used during your session.Consent(Required) I agree to the policy.I understand the importance of informing my massage therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.Consent(Required) I agree to the policy.I understand that it is my responsibility to inform my massage therapist during the session, not afterwards of any discomfort but not limited to pressure, draping, in positioning body or head. So, the massage therapist can adjust or change or drape over accordingly. This would include while massaging or MPS treatments/scar Therapy, draping does move during session, but is required to all areas and including all Male or Female areas. These areas will be covered with sheet/blanket or towels during full session period.Consent(Required) I agree to the policy.I understand that I (Patient) or the massage therapist may terminate the session at any time but patient will be charged for full session.Consent(Required) I agree to the policy.I understand that if I am having MPS/Scar Therapy, I give my therapist permission to treat scars on areas that include abdominal/hip scars, upper extremities or lower extremities, head/neck/spine and will be draped according. We require at least 5 to 8 sessions for Scar Release Therapy. Decided during Initial Evaluation sessionConsent(Required) I agree to the policy.Inappropriate Behavior Policy — Massage therapy is for relaxation and therapeutic purpose only. There is no sexual component to massage whatsoever. Any insinuation, joke, gesture, conversation, or request otherwise will result in immediate termination of your session and a refusal of all services in the future. You will be charged the full-service fee regardless of the length of your session. You are required during your session to info your therapist of draping moving and release therapist of risk of any hand positioning while treatments are being completed, for this professional session. Treat your therapist with respect and dignity and you will be treated the same in return.Consent(Required) I agree to the policy.I have been given a chance to ask questions about the massage therapy session and my questions have been professionally answered.Consent(Required) I agree to the policy.Late/Cancellation Policy — We respectfully ask that you provide us with 24 hours’ notice and Friday before an upcoming Monday any schedule changes or cancellation requests. Please understand that when you cancel or miss your appointment without providing a 24 hour notice we are often unable to fill that appointment time. This is an inconvenience to your therapist and other clients miss the chance to receive services they need. For this reason, you will be charged (50%) of service fee for the first missed session and (100%) of service fee for each session after that. We understand that emergencies can arise, and illness do occur at inopportune times. If you have a fever, vomiting or diarrhea within 24 hours prior to your session time, we request that you cancel your session. We know inclement weather may result in the need for late cancellations. We will do our best to give you advance notice if we are closing or need to cancel due to bad weather and we ask you to do the same. We might require a credit card to be kept on file if you cancel without notice more than two times.Consent(Required) I agree to the policy.Payments for session are done at end of treatments, we accept CASH / CREDIT CARDS (with a processing charge) or CHECKS (Returned will be charged $35 and legal fees)BY SIGNING THIS FORM, YOU INDICATE THAT YOU VOLUNTARILY ACCEPT TO UNDERTAKE THIS HEALTH PROGRAM AND YOU RELEASE ALLEN T. STANLEY, PRACTITIONER AND ALL TEAM MEMBERS FROM ANY AND ALL COMPLICATIONS THAT MAY ARISE FROM ANY OF THE SUGGESTED OR OFFERED THERAPIES, INCLUDING BUT NOT LIMITED TO RED LIGHT THERAPY, AO SCAN, TERAHERTZ, SOMATIC, MEDICAL MASSAGE, ULTRASOUND, MPS ACUPUNCTURE, THETA CHAMBER, RAIN ION CHAIR, ZIP SYSTEM, AO INFINITY WAND, RF FOOT DETOX, PELVIC PULSE CHAIR AND ESSENTIAL OILS. I ALSO AGREE TO ALL THETA CHAMBER GUIDELINES AND RELEASE KEEP YOUNG WELLNESS CENTER LIABILITIES.