INFORMED CONSENT
BY BOOKING AN APPOINTMENT, I AGREE TO RECEIVE MASSAGE FROM VETIVER
THERAPIES, AND/OR JILL JURKOWSKI, LMT. I UNDERSTAND THAT MASSAGE
THERAPY IS INTENDED TO ENHANCE RELAXATION, REDUCE PAIN OF MUSCLE
TENSION AND PROVIDE A POSITIVE AND SAFE EXPERIENCE WITH TOUCH. I
AM AWARE THAT MY MASSAGE PRACTITIONER DOES NOT DIAGNOSE DISEASE
OR ILLNESS, PRESCRIBE MEDICATIONS OR PERFORM SKELETAL
MANIPULATIONS. I COMPREHEND THAT I MAY TERMINATE A MASSAGE
SESSION AT ANY TIME IF I FEEL UNCOMFORTABLE WITH THE COURSE OF
TREATMENT. THE THERAPIST RESERVES THE RIGHT TO END A SESSION IN
THE CASE OF ANY INAPPROPRIATE BEHAVIOR. THE BENEFITS OF MASSAGE
THERAPY AND POSSIBLE CONTRAINDICATING FACTORS, AND TREATMENT
PLAN HAS BEEN EXPLAINED TO ME. I REALIZE THE HEALTH BENEFITS OF
MASSAGE THERAPY ARE NOT GUARANTEED, NOR IS MASSAGE TO BE A
SUBSTITUTE FOR SUPERVISED MEDICAL TREATMENT BY A DOCTOR. I
HEARBY ASSUME FULL RESPONSIBILITY FOR RECEIPT OF MASSAGE THERAPY, I
RELEASE AND DISCHARGE THERAPIST FROM ANY CLAIMS, DAMAGES OR
CAUSES OF ACTION ARISING FROM THE THERAPY RECEIVED HENCEFORTH,
INCLUDING, WITHOUT LIMITATION, ANY DAMAGES ARISING FROM ACTS OF
PASSIVE NEGLIGENCE ON THE PART OF THE THERAPIST, TO THE FULLEST
EXTENT ALOWED BY THE LAW.
24- HOUR CANCELLATION POLICY:
I UNDERSTAND THAT THIS TIME HAS BEEN RESERVED FOR ME, AND IF I AM
UNABLE TO MAKE A SCHEDULED APPOINTMENT, I AGREE TO NOTIFY THE
THERAPIST WITHIN 24 HOURS BY TELEPHONE. I UNDERSTAND THAT THIS 24
HOUR NOTICE IS REQUIRED TO AVOID BEING CHARGED A MISSED
APPOINTMENT CHARGE OF 50% OF THE SCHEDULED TREATMENT FEE.
I ACKNOWLEDGE RECEIPT AND COMPREHENSION OF THE POLICIES SET
FORTH BY VETIVER THERAPIES AND BY SCHEDULING AN APPOINTMENT
AGREE TO THE POLICIES STATED ABOVE.