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General Liability Release Form

 

By signing below, you agree to the following:

I give my permission to receive Massage Therapy and Bodywork. Massage Therapy consists of Deep Tissue, Deep "Hot" Stones, Trigger Point, Myofasical Release and Stretching. Bodywork consists of Cupping and Scraping. Additional and alternative treatments include Red+Near+Far Infrared Light Panels and Mat. 

I understand that therapeutic Massage and Bodywork is not a substitute for traditional medical treatment or medications.

I understand that the massage therapist does not diagnose illnesses or injuries or prescribe medications.

I have clearance from my physician to receive Massage Therapy and Bodywork.

I understand the risks associated with Massage Therapy and Bodywork include, but are not limited to:

  • Superficial bruising 
  • Short-term muscle soreness, tenderness, achiness
  • Skin discolorations, friction burns, blisters, raised indentations
  • Extreme temperatures with "hot" stones & BioMat®
  • Exacerbation of undiscovered injury
  • Aggravating an older injury
  • Lingering pain
  • Muscle aches or Fatigue
  • Headaches/Migraines
  • Sleepiness
  • Inflammation
  • Swelling
  • Redness or Heat (Skin)
  • Nausea
  • Flu-like symptoms

I therefore release Muscle Rehab & Recovery Co., Muscle Rehab with Audrey and Audrey Kosclski LMT#128528 from all liability concerning these injuries that may occur during the massage session. 

I understand I will be receiving Deeper Muscle Work including, but not limited to deep pressure, deep tissue techniques, deep stones, cupping therapy, muscle scraping, stretching and light therapy.

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.

I understand if I have deep vein thrombosis (DVT), I should NOT receive any Massage & Bodywork treatments. Partaking in these sessions may increase the risk of potential fatal blot clots. 

I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so she may adjust accordingly.

I understand that I or the massage therapist may terminate the session at any time.

I understand the risks of all the services provided by Muscle Rehab & Recovery Co., Muscle Rehab with Audrey and Audrey Kosclski LMT#128528. 

I have been given a chance to ask questions about the massage therapy session and my questions have been answered

Today's Date: May 15, 2025

 

 


First Client's Name
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First Client's Date of Birth*
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Second Client's Name
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Third Client's Name
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Fifth Client's Name
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Sixth Client's Name
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Eighth Client's Name
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Ninth Client's Name
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Tenth Client's Name
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Client's Date of Birth*
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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Client's Age Acknowledgment*
Client's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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