Informed Consent Agreement – Massage Therapy Services

Welcome to the Dempsey Centers for Quality Cancer Care. Our mission is to provide quality of life services to individuals and families impacted by cancer, including massage therapy to help with physical symptoms and stress-related symptoms presented by the cancer impact and/or loss of a loved one to cancer.

If you are reading this form, you have chosen to utilize our massage therapy services.

Massage Therapy Services: We provide massage therapy services by licensed massage therapists. Our massage therapy services are intended for stress reduction and relieving muscle tension, and may also help to ease other cancer-related symptoms such as pain, anxiety, fatigue, nausea and depression. Massage therapy is not intended to constitute, and is not a substitute for medical care. Services will not include skeletal adjustments, diagnoses, or prescriptions, and nothing said or done in the course of the massage sessions should be construed as such.

Your first visit will include an assessment, during which you and your massage therapist will review your health history, determine your concerns and goals, and if both agree to proceed, a plan for further sessions will be developed. The goal of our massage therapists is to provide the most effective therapeutic experience available to you that will enhance your quality of life.

Massage therapy sessions are typically 45 minutes in length and we provide up to 8 sessions for patients and 6 sessions for those who are designated as primary care partners.

Risks:Massage therapy is usually beneficial for most clients, but there are no guarantees as to the nature or extent of any particular result and as with any treatment, there are potential, inherent risks. Complications may arise from receiving massage therapy, including bruising, lymphedema, bone fracture, causing a new injury, exacerbating an existing injury or condition, dislodging a blood clot, skin injury, fatigue, dizziness and/or vertigo, inflammation, nausea and headaches/migraines.

Contraindications: Certain contraindications may exist to massage therapy, and it is your responsibility to inform your massage therapist if you are pregnant or have been vomiting, or if you have any of the following: contagious disease, diarrhea, a fever, kidney disease, congestive heart failure, bone metastases, known or suspected deep vein thrombosis, COPD, bruising or bleeding disorder, lymphedema, platelet counts lower than 10,000 (thrombocytopenia) or white blood cell counts lower than 1,000 (neutropenia).

If any of these conditions exist, massage therapy may not be appropriate for you at this time.

Medical Clearance: Please know that we will require a medical clearance from your medical provider before we will render massage therapy services. We will send a form for this purpose directly to your designated provider.

My signature on this Informed Consent Agreement for Massage Therapy Services indicates that I:

• Have reviewed, understand, and consent to the information above.
• Have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me.
• Consent to receive massage therapy services,
• I understand that I may stop such treatment or services at any time
• Agree that I will inform my massage therapist if I have any of the conditions or risks listed above under “Contraindications”
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I understand that my typed name above will carry the same effect as my written signature(Required)