Consent Forms

Massage for the Entire Family. In-Home Healthcare and Group Classes.

Available Courses

Provider Consent Form 

To: Cynthia Scott, LMT, BCTMB, CLT, COMT, CPMT

945 Sgt. Ed Holcomb Blvd. Conroe, Tx. 77304

(682)463-9143





INFORMED CONSENT TO MASSAGE THERAPY TREATMENT

I understand that the massage therapist is providing massage therapy services within their scope of practice as defined by the State of Texas.

 

I have reviewed the attached Plan of Care: techniques, pressure levels and precautions being used for my patient.  


I acknowledge that the therapist is not a physician and does not diagnose illness or disease or any other physical or mental disorder. It  is understood that massage therapy is not a substitute for a medical examination.  It is the responsibility of the patient to keep the massage therapist updated on their medical history.


Physician  Name _______________________________________________________________________________________

 

 Signature______________________________________________________________________________________________

 

Date____________________________________________________________________________________________________