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Hot Stone Massage Release Form

Hot stone massage is not suitable for everyone. There are risks associated with performing hot stone massage on individuals with the following conditions.


You must inform your massage therapist/practitioner if you have any of the following conditions which may make hot stone massage contraindicated or may require your therapist/practitioner to alter the massage.

∙ Pregnancy 

∙ Blood clot(s) 

∙ Diabetes 

∙ Neuropathy 

∙ Inflammatory skin conditions 

∙ Autoimmune condition (MS, Lupus, RA, etc.) 

∙ Open wounds or sores 

∙ Peripheral vascular disease 

∙ Hypotension or Hypertension

∙ Heat sensitivity 

∙ Cancer (with or without treatment) 

∙ Compromised immune system 

∙ Varicose veins

∙ Edema or Lymphedema 

∙ Under the influence of drugs or alcohol 

∙ Cardiovascular disease 


Client’s Release 

I have read and understand the aforementioned conditions  which make hot stone massage contraindicated. The massage therapist/practitioner has discussed this  information with me and provided opportunity for any questions. I have disclosed any and all health risk factors. 


Please check the following that applies to you.

Fecha
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