Cancer Massage Consent Form

Please complete this consent form before your appointment. All required fields must be completed before submitting.

About Cancer Massage

Cancer massage, also called oncology massage, refers to massage therapy that is offered to people with cancer. It is not used as a treatment for cancer, but rather an integrative therapeutic intervention to relieve some symptoms associated with cancer, or side-effects of certain cancer treatments. Massage therapy may help relieve symptoms such as pain, muscle tension, anxiety and depression, as well as stimulate the release of endorphins and lower stress hormones. It is also useful in improving the patient's sense of wellbeing and quality of life. Massage for people with cancer may involve the use of several types of massage and bodywork such as Swedish, aromatherapy, myofascial release, shiatsu, and trigger point therapy.

Contraindications for Cancer Massage

In addition to the standard contraindications for massage, cancer massage has additional contraindications and precautions. Whether or not it is safe to proceed with massage for an individual with cancer depends on numerous factors including: type of cancer, stage of cancer, current symptoms, comorbidities, and other treatments that the patient is receiving.

The following is a partial list of common conditions which are considered contraindications for cancer massage therapy:

Blood clots
Bleeding disorders
Infection
Skin lesions
Pitting edema
Heart disease
Impaired immune function
Unexplained symptoms

Please Read and Initial Each Item Below

Please initial each statement below to confirm that you have read, understood, and agreed to the information provided.

Initials(Required)

Information about cancer massage, potential benefits, effects, risks, and possible alternative therapies have been explained to me and I understand this information.

Initials(Required)

My therapist has informed me of the contraindications of cancer massage, and I have provided my therapist with an accurate and complete medical history to rule out any contraindications to receiving this treatment.

Initials(Required)

I have been given an opportunity to ask questions about cancer massage and have had my questions answered to my satisfaction.

Initials(Required)

I am receiving regular medical checkups from my physician / healthcare provider.

Initials(Required)

I have received medical clearance to receive massage and have no contraindications for massage.

Date you spoke with your oncologist about receiving massage therapy

Initials(Required)

I agree to communicate to my therapist any physical discomfort experienced during the session.

Initials(Required)

I agree to communicate to my therapist any physical discomfort experienced during the session.

I have received, am currently receiving, or will likely receive the following medical interventions:

Chemotherapy

Radiation therapy

Surgery

Other

Other medical intervention

I further understand that massage is not a substitute for a medical examination or treatment, and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware.

I understand that massage therapists do not diagnose illness or disease, and nothing said during the treatment should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.

Name(Required)

First Last

Todays Date(Required)

Signature(Required)

Pregnancy Due Date(Required)