Consent for Assessment and Treatment of Sensitive Areas
I, ________________________ (name), have requested assessment and/or treatment by this Registered
Massage Therapist (RMT) ________________________ (name) for treatment of the clinically relevant
areas indicated below (please initial):
___Chest Wall Muscles (not including breasts)
___Breast (s)
___Buttocks (gluteal muscles)
___Upper Inner Thigh(s)
List Clinical Indication: _____________________________________________________________
The RMT has explained the following to me and I fully understand the proposed assessment and/or
treatment:
• The nature of the assessment, including the clinical reason(s) for assessment of the
above area(s) and the draping methods to be used
• The expected benefits of the assessment
• The potential risks of the assessment
• The potential side effects of the assessment
• That consent is voluntary
• That I can withdraw or alter my consent at any time.
I voluntarily give my informed consent for the assessment and/or treatment as discussed and outlined
above.
Client Name (print): _____________________________________________________________
Client Signature: _________________________________________Date: _________________
Ongoing Treatment:
I am aware that the treatment of the above indicated area(s) is part of a treatment plan which has been
discussed with me by my RMT. I confirm that, on the following date(s), the RMT has reviewed the
treatment plan and I provide my informed consent.
Client Signature: ____________________________________Date: _______________
Client Signature: ____________________________________Date: _______________
Client Signature: ____________________________________Date: _______________
Client Signature: ____________________________________Date: _______________
Client Signature: ____________________________________Date: _______________
