Sample informed consent form
East Vancouver Therapeutic Massage Clinic
Patient's name
- Consent to treatment areas circled below
- Any areas not to be treated are crossed off and bold
- I agree to allow my RMT to share the contents of my patient record with other RMTs working at East Vancouver Therapeutic Massage Clinic for clinical/legal/educational purposes only. Information will only be released to a third party with my signed consent.
- I agree to the treatment as outlined on the above anatomical diagram. I understand my treatment plan may change and that my RMT will discuss any new areas to be treated. I have crossed off any areas on the above anatomical diagram that I do NOT want to be treated
- The risks of treatment on the circled areas have been discussed with my RMT.
- I understand I have the RIGHT TO WITHDRAW CONSENT AND HAVE THE TREATMENT STOP AT ANY TIME. I understand I have the right to ask my RMT question at any time about my treatment plan.
Patient Signature___________________________________ Date____________________________