Introduction:
Communication:
As massage therapists we understand the importance of communication. However, as our work becomes second nature to us, we may forget that for some of our clients the experience can be new, stressful, or difficult. The consent form below is one more opportunity to clearly discuss certain aspects of a massage therapy treatment with patients/clients before the treatment happens, and thereby allow for an increased sense of control and safety. For most people, it is helpful to understand the rationale behind touching private areas and draping variances, and to understand that they have a choice.
This is an opportunity to educate clients on their right to change consent at any time during a treatment (which from experience we know not everyone feels they “should”). Additionally, it educates them on the LMT’s legal responsibility to obtain written consent, so patients will have more clarity when encountering uncomfortable or inappropriate situations which unfortunately exist.
How to use the Consent Form:
The consent form below is provided in Word format to allow you to change it in any way to adapt it to your specific practice. You only ask for consent for sections which you anticipate will be relevant to the treatment by marking them, and have the client initial those.
If during the course of the treatment, or at the beginning of another treatment, you find it advisable to work in ways which require additional consent, it is time to pause, explain your proposed treatment to your patient, and again ask for their consent. If they are agreeable, they can then initial and date the appropriate section of the consent form. Additionally, discussions during Board of Massage meetings indicate that the board’s interpretation of the rule is that written consent needs to be on file, and verbal consent needs to be given at each session. WSMTA recommends that verbal consent should be noted in the treatment records each time. You can find the new massage WAC rules at:
Can I simplify the process by having patients just initial everything on the form?
Most complaints, to employers of LMT’s, to the Department of Health, or to your patient’s friends and family, have to do with lack of communication between therapist and patient. By asking for a blanket consent, you are missing a valuable opportunity for communication.
Please consider having your legal council check any forms you are using in your practice as they become legal documents once they are part of a patient file.
Special Consent for Massage Therapy
Please initial those marked below. Please ask your therapist any questions you have regarding treatments, or let them know if you are uncomfortable in some way regarding the requested consent.
Consent for Breast/Chest Massage:
( ) Massage of Breast Tissue: Some types of treatment require massage of the breast tissue. Specifically, Manual Lymphatic Drainage for the treatment of edema requires massage of both the affected and unaffected side. WAC 246-830-555 requires your special written and verbal consent for breast massage, your massage therapist to have 16 hrs. of specialized training for this work and that any massage involving the nipple and areola requires a doctor's prescription specifying the medical need for massage therapy of the areola/nipple or your special written and verbal permission separate from breast massage. Prior to each massage, your massage therapist will thoroughly explain what is going to be massaged and why. Even though you consent to breast massage today you can choose not to receive it at any point of your treatment or limit the massage.
I consent to breast massage. ______
I have provided the required doctor’s referral, and/or consent to massage of the areola / nipple of my right / left breast. ______
( ) Massage of tissue around or deep to breast/chest tissue: In order to achieve treatment goals, your therapist might deem it appropriate to work on muscle or connective tissue near or underneath breast/chest tissue (for example, pectoralis or intercostal muscles). Your therapist will do their best to avoid breast tissue and minimize pressure. Please let them know any time treatment feels uncomfortable in any way.
I consent to my breasts/my chest being touched during the massage treatment for the purpose of working with surrounding or deep structures. ______
I prefer not to be touched on or near my breasts/chest. ______
Consent for Draping Variances:
State law requires that draping is provided during a massage and ensures that the following areas will not be exposed during a massage: Breast/chest, genitals, and gluteal cleft. There are several exceptions:
●Temporary removal of draping can occur for the gluteal cleft area and breasts with written, verbal and signed informed consent.
●Breast draping may be removed for the duration of the full session with written, verbal and signed informed consent.
( ) Breast/chest: I consent to my breast being uncovered during breast massage. ______
( ) Torso (males only): I consent to having my torso uncovered/undressed during the full massage ______(This option is for LMTs who do not do breast massage at all, but do not want to inhibit men from exercising their choice to keeping their chest uncovered. If your style of massage or personal preference provides the option to have the torso uncovered for men and women, edit this option).
( ) Assistance with dressing/undressing: I require assistance with undressing and dressing, which may expose my breasts and gluteal cleft area.
I consent to assistance. ______
Intraoral Massage:Your therapist may deem it advisable to work inside your mouth to achieve your treatment goals. She/he has the required licensing endorsement.
( ) I consent to intra-oral work. ______
Perineal Massage:Your therapist may deem it advisable to work on your perineal area to achieve your treatment goals. She/he has the legally required 16 hrs. of specialized training for this work. Prior to each massage, your massage therapist will thoroughly explain what is going to be massaged and why. Even though you consent to perineal massage today you can choose not to receive it at any point of your treatment or limit the massage. Both written and verbal consent must be provided.
( ) I consent to massage of the perineal area. ______
I understand that I have the right to rescind my consent and refuse any of the above treatments at any time, even in the middle of a treatment session. The consent is valid until I inform my therapist that I want to change it.
( ) I have received a copy of the consent form.______
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Patient Name& Guardian Name (if applicable) (Printed)
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Patient/ Guardian Signature Date
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Massage Therapist Name
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Massage Therapist Signature Date