– Sensitive Area Consent

– Sensitive Area Consent Form

I (State Your Name) *

have requested assessment and/or treatment by Amy Reitzel, Registered Massage Therapist (RMT) for treatment of the clinically relevant areas indicated below (please initial in relevant areas): *

• Upper inner thigh musculature
• Gluteal (hip region) musculature
• Hip flexor (quads) musculature
• Chest wall musculature
• Pubic symphysis joint
• Breast tissue

Amy Reitzel has explained the following to me and I fully understand the proposed assessment and/or treatment including (please initial to indicate that the following items below were discussed): *

• The nature of the assessment, including the clinical reason(s) for assessment and/or treatment of the above area(s) and the draping methods to be used.
• The expected benefits, and potential risks and side effects of the assessment and/or treatment.
• Alternative courses of actions.
• Likely consequences of not having the treatment.
• That consent is voluntary.
• That I can withdraw or alter my consent at any time.

I voluntarily give my consent for the assessment and/or treatment as discussed and outlined above. From here- forth, I agree that verbal permission at the beginning of each treatment is sufficient consent for the RMT to assess and treat these sensitive areas as needed. Consent for sensitive areas will be documented by the RMT in my file each session. *

• I agree
• I disagree

Signature *

Date *

Submit