Hot Stone Massage Informed Consent

Below is a sample of a Hot Stone Informed Consent. In the Members only area members are able to access the PDF/Word Document to make their own custom changes and see complete form.

I hereby request and consent to the performance of hot stone massage on me (or on the client named below, for whom I am legally responsible) by the massage therapist named above and/or any other massage therapist who now or in the future treat me while employed by, working or associated with or serving as back-up for the massage therapist listed above, and by any other massage therapist working at the facility listed above or any affiliated facility, whether signatories to this form or not.

I understand that hot stone massage involves heating stones, then using those stones during the course of massage, either by the massage therapist placing those stones on me to warm and relax muscles or by the massage therapist holding those stones in their hands and then massaging me with those stones.

I have been informed that hot stone massage is a generally safe method of massage, but that it may have some side effects, including, in particular, burns and or related scarring as a result of the contact of the hot stones with my skin. I understand that even with proper care by the massage therapist, it is nearly impossible to predict the precise manner in which a stone will retain heat when warmed and dissipate heat when placed in contact with the body. Variations in this heat transfer process could result in an unexpectedly high rate of heat transfer, and subsequent tissue damage. Further, the visual evidence that a bum is developing typically does not occur until after tissue damage has already happened. Even when both the massage therapist and the client are diligent, conditions leading to burns may still go unnoticed until after the burn has already occurred.

In addition, I understand that a variety of medical conditions which I might have, and which my massage therapist has neither the training, nor the legal right to interpret, could increase the risk of burns for me. For example, I realize that if I have diabetes or any other condition that reduces circulation, the risk of bums is substantially increased. Reduced circulation may limit the ability of the body to properly dissipate heat from a specific location, which could result in a bum. Limited circulation may also result in reduced sensitivity to the presence of heat. Without my input that a stone is too hot for my skin, the massage therapist may have no reasonable way of knowing that there is a problem before it is too late, and a burn has occurred.

I understand that another condition that impacts the risk associated with burns is the sensitivity of ........

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