945 Sgt. Ed Holcomb Blvd
Conroe, Texas, 77304
Massage for the Entire Family. In-Home Healthcare and Group Classes.
Provider Consent Form
To: Cynthia Scott, LMT, BCTMB, CLT, COMT, CPMT
945 Sgt. Ed Holcomb Blvd. Conroe, Tx. 77304
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 _______________________________________________________________________________________