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Hot Pack Consent & Release Form

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About Hot Pack Massage Therapy

Hot pack, also called hydrocollator, massage therapy is a type of massage therapy that uses the application of moisture-retaining hot packs heated to a therapeutic 160°F to 170°F to target areas of the body and provide a relaxing, warming effect during therapeutic massage.

Contraindications for Hot Pack Massage Therapy

In addition to the standard contraindications for massage, hot pack massage therapy has additional contraindications and precautions. The following is a partial list of common conditions which are considered contraindications or precautions for hot pack massage therapy:

  • Hematoma
  • Infections
  • Cardiovascular disease
  • Autoimmune conditions
  • Cancer
  • Neuropathy
  • High / low blood pressure
  • Edema / lymphedema
  • Diabetes
  • Sunburn / rash
  • Bleeding disorder
  • Skin lesions or open wounds
  • Pregnancy
  • Heat sensitivity
  • Certain medications
  • Acute injuries or conditions

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.

Information about hot pack massage therapy, potential benefits, effects, risks, and possible alternative therapies have been explained to me and I understand this information.
My therapist has informed me of the contraindications of hot pack massage therapy, and I have provided my therapist with an accurate and complete medical history to rule out any contraindications to receiving this treatment.
I understand that the temperature of the hot packs should always be within my comfort level, and I agree to communicate to my therapist about any physical discomfort that I experience during the session.
I have been given an opportunity to ask questions about hot pack massage therapy and have had my questions answered to my satisfaction.
I have no contraindications for hot pack massage therapy.
I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment.

I further understand that hot pack massage therapy 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.