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Advanced Therapies Consent Form

First name

Last name

Contraindicated Medical Conditions for Advanced Treatments:

Pregnancy
Blood clot(s)
Diabetes
Neuropathy
Inflammatory skin conditions
Autoimmune condition (MS, Lupus, RA, etc.)
Open wounds or sores
Peripheral vascular disease
Hypotension or Hypertension
Heat sensitivity
Cancer (with or without treatment)
Compromised immune system
Varicose veins
Edema or Lymphedema
Under the influence of drugs or alcohol
Cardiovascular disease

I understand the information contained on this form and confirm that I do not have any of the above conditions.

I understand that my pre-existing medical conditions contraindicate me for advanced massage treatments including but not limited to cupping, hot stones, and/or LED. I take full responsibility for any and all complications which may happen due to utilizing this treatment.

I have researched the advanced treatments and are aware of the risks of each treatment offered.

I waive all liability of Transcendence Massage & Yoga LLC and/or the LMT who performed the treatment who is proceeding in good faith with this treatment in accordance to the information I have provided.

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