Written Consent for the Treatment of Sensitive Areas
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.
I have discussed the treatment and/or treatment plan with ______________________________, MT.
During this discussion, the benefits, risks and side effects, areas to be treated, positioning and draping
(covering) to be used have been explained to me.
I understand the following sensitive areas will be treated by _____________________________, MT
for the following reasons:
Sensitive Area Clinical Indication for Treatment
Inner thigh
Buttocks (gluteal muscles)
Chest wall musculature
Breast tissue
If I have consented to breast massage, I understand that the nipples and areolas of my breasts will not
be touched during the treatment.
I have had the opportunity to ask questions about the above information and I know I can ask any
questions that I have, as a result of the treatment or further discussion, at a later date. I also understand
that I can alter or withdraw my consent for this treatment and/or treatment plan at any time during this or
any other treatment. A record of this consent will be kept in my client file held by
______________________, MT.
It is with the above understanding that I consent for the treatment of the sensitive areas as indicated.
Client’s signature:
_______________________________________________
Date:
_______________________________________________
Name (please print):
_______________________________________________
Therapist’s signature:
_______________________________________________
Name (please print):
_______________________________________________
