Hot Stone Massage Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Email: *

Contact Number: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently (or possibly may be) pregnant? *

Do any of the following apply to you? Please tick all that apply.

Do you have any other medical conditions? *

Please list: *

Have you had any significant accidents, injuries, surgeries, seizures etc.? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Consultation

What is your occupation? *

Do you suffer from chronic pain? *

Please explain: *

What makes it better? *

What makes it worse? *

Please rate your quality of sleep on a scale of 1 (Bad) to 5 (Excellent): *

Please rate your energy levels on a scale of 1 (Bad) to 5 (Excellent): *

Please rate your stress levels on a scale of 1 (Bad) to 5 (Excellent): *

Please rate your quality of nutrition on a scale of 1 (Bad) to 5 (Excellent): *

Please rate your exercise habits on a scale of 1 (Bad) to 5 (Excellent): *

Have you had a hot stone massage before? *

What are your goals for this treatment session? *

Please list any areas of discomfort (including which side of the body):

Treatment Information

What is hot stone massage therapy?

Hot stone therapy is a specialist massage that uses smooth, flat, heated basalt stones that are positioned along your spine, in the palms of your hands, along your legs and between the toes. Typically from river beds, basalt stones are used for massage as they have a rich iron content that retains heat. Cold marble stones are often used in the treatment to help aid with detoxing and healing the body.

How does hot stone massage therapy work?

Your therapist will warm the stones in water until they are within the precise temperature range of between 120 and 130 degrees Fahrenheit.

A hot stone massage may begin with a traditional Swedish massage technique to prepare your muscles. Your therapist will then place the warm stones on key acupressure points on your body. The stones warm and relax your muscles, allowing deeper pressure to be applied during your massage.

Using massage oil and a combination of strokes and techniques, your therapist will massage your neck, back, arms and legs, with and without the stones. You should always tell your therapist if the stones are too warm or the pressure is too intense.

Allow plenty of time for your hot stone treatment; arrive 10 minutes early to allow yourself time to relax. If it is your first time, you’ll be asked to complete a pre-treatment health questionnaire. Avoid eating a heavy meal or drinking alcohol prior to the treatment.

The origins of hot stone therapy can be traced back to over 2,000 years ago, when the Chinese used heated stones more than 2,000 years ago as a means of improving the function of internal organs. You can read more about the history of stone therapy on our blog.

What are the benefits of hot stone massage therapy?

The combination of hot and cold stones encourages your body to detox and heal through increasing your lymphatic flow and encouraging your body to remove waste products.

Some other benefits of hot stone massage include:

relaxing tense muscles
aiding pain relief
alleviating depression
promoting sleep
improving circulation

Hot stone therapy helps people who suffer from:

stress
back pain
muscular pain
fibromyalgia
insomnia
depression or anxiety
poor circulation

Consent

You may feel sore during your massage or the day after. This may be due to deep tissue manipulation and pressure. You shouldn’t feel pain. If you are uncomfortable or experience pain during your massage, let your massage therapist know right away.

If I experience any pain or discomfort during the session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort.
I further understand that Massage Therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware.
Because Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly.
I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I fail to do so.
This is a Therapeutic Massage session and any sexual remarks or advances will terminate the session and I will be liable for payment of the scheduled treatment.
I understand the Massage Therapist practitioner reserves the right to refuse services to me for any reason that she/he deems necessary.

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive Hot Stone Massage Therapy.

Client Signature: *

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