I, Jane Doe, am a Massage Therapist. I am not a licensed physician. Massage therapy services for healing purposes are not licensed by the state of California. I am licensed as a massage therapist by the city of Walnut Creek. 

I perform Swedish Massage combined with deep tissue.  These techniques improve circulation, relieve pains and aches and combined with pressure point therapy relax not only specific muscles but the entire body.

I have received my training and education at the McKinnon Institute (Swedish & deep tissue).

In order to use my services, California state law requires that you acknowledge receipt of the information provided in this form and that you sign it. You will receive a copy. I will keep the original in my records for at least three years.

My methods of treatment, massage therapy and bodywork, are alternative or complementary to healing arts that are licensed by the State of California. Under Sections 2053.5 and 2053.6 of California’s Business and Professions Code. 

If you ever have any concerns about the nature of your treatment, please feel free to discuss them with me. I recommend that you inform your medical doctor that you are receiving bodywork.

Acknowledgement and Consent to Receive Services

I have read and understand the above disclosure about the massage therapy offered by Jane Doe and Jane Doe's training and education. I have discussed with Jane Doe the nature of the services to be provided. I understand that Jane Doe is not a licensed physician and that massage therapy and bodywork services are not licensed by the state. I understand it is my responsibility to maintain a relationship for myself/my child with a medical doctor. I have consented to use the services offered by Jane Doe, and agree to be personally responsible for the fees of Jane Doe in connection with the services provided to me.


Signed:  ___________________________                               Date:  ________________________




                (name of client)