Name *

First Name

Last Name

Phone *

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Date *

MM

DD

YYYY

I confirm that I have completed the Spa’s health history questionnaire honestly and completely, and I will promptly inform Kevin Biesinger of any changes in my health status, new medications, injuries, illnesses, or other relevant conditions. *

I acknowledge

I understand that the massage services I receive are not a substitute for medical care, diagnosis, or treatment, and I will seek the advice of a qualified health professional as needed. *

I acknowledge

I consent to the massage therapy (manual soft-tissue manipulation) as described, and I acknowledge that no guarantees have been made regarding specific outcomes or therapeutic results. *

I acknowledge

I understand that the provider will follow the Utah Massage Therapy Code of Ethics & Standards of Practice, including but not limited to: providing services within the licensed scope, maintaining professional boundaries, using appropriate draping (covering the genitals). dopl.utah.gov+2Avvo+2 *

I acknowledge

I understand that draping will be maintained at all times to ensure my comfort and modesty, and I may request adjustments in draping or pressure at any time. *

I acknowledge

I understand that the therapist will create a safe, comfortable, hygienic environment, use professional communication, and follow standard precautions and hygiene protocols. *

I acknowledge

I understand that the services provided do not include diagnosing medical conditions, performing chiropractic adjustments/techniques outside of the scope of massage therapy, or treating disease beyond the scope of licensed massage therapy in Utah. *

I acknowledge

I understand that I have the right to decline or stop any part of the session at any time and to ask questions about any technique being used. *

I acknowledge

I agree to arrive on time for my scheduled session. I understand that if I arrive late, my session may be shortened so the next client is not delayed and full session fee may apply. *

I acknowledge

I agree to pay the full session fee at the time of service (unless other arrangements have been agreed in writing). *

I acknowledge

I agree to give at least 24 hours’ notice for cancellation or rescheduling; if I cancel with less than 24 hours’ notice or do not show, I understand I may be charged a cancellation or no-show fee as set by Renú Men’s Spa. *

I acknowledge

I understand that if I am under the influence of alcohol and/or drugs (that impair my ability to participate safely) the therapist may refuse service. *

I acknowledge

I understand I will keep my hands and feet clean prior to the session, remove jewelry or piercings if requested, and follow any pre-session guidelines provided by the Spa.
 *

I acknowledge

I understand the professional boundaries of the client–therapist relationship: the session is therapeutic, not social or sexual in nature. I agree to behave respectfully, and not request sexual or erotic services. The therapist retains the right to terminate the session immediately if boundaries are violated, and I may still be responsible for the fee. *

I acknowledge

I understand I should communicate any discomfort, pain, or desire to change pressure, technique or body area during the session. *

I acknowledge

Client rights: I have the right to ask for the provider’s name, license type, and view the license (as required). I have the right to informed consent, confidentiality of my health information, respectful treatment, and to stop or modify services at any time. *

I acknowledge

Therapist rights: The therapist has the right to refuse or terminate service if the client behaves inappropriately, is uncooperative, exhibits unsafe behavior, or if the therapist determines the client’s health condition makes massage unsafe. The therapist has the right to expect timely payment, observance of scheduling policies, and respect of professional boundaries. *

I acknowledge

I understand that the therapist will maintain a client record of my health history, session notes and informed consent. I understand how my personal information is handled, and that confidentiality will be maintained except as required by law. *

I acknowledge

I understand that under Utah law, the therapist must not massage the genitals or the anus of a client. *

I acknowledge

I understand that although massage therapy is generally safe, there are risks inherent with bodily manipulation including but not limited to soreness, bruising, temporary increase in pain, injury, allergic reaction to oils/lotions, or aggravation of existing conditions. *

I acknowledge

In consideration of the services provided to me by Kevin Biesinger, LMT, and Renú Men’s Spa, I hereby release, waive and discharge the therapist and Spa, their officers, employees, agents, and assigns (collectively, “Released Parties”) from any and all liability, claims, demands, actions or causes of action arising out of or relating to any loss, damage, injury, or death, whether caused by the negligence of the Released Parties or otherwise, that may result from my participation in the massage sessions. *

I acknowledge

I hereby agree to indemnify, defend and hold harmless the Released Parties from any liability, loss, cost or expense (including attorney’s fees) resulting from claims by third parties arising out of or connected to my actions or omissions during the sessions. *

I acknowledge

I expressly assume full responsibility for any risks, whether known or unknown, and I hereby consent to receive massage therapy services. *

I acknowledge

I understand that this waiver and release is intended to be broad and inclusive. If any portion is held invalid, the remainder shall continue in effect. *

I acknowledge

I affirm that I have read, understand and voluntarily acknowledge each of the above sections. *

I acknowledge

I understand that this Agreement covers all massage therapy services provided by Kevin Biesinger, LMT at Renú Men’s Spa, unless specifically superseded by a separate written agreement. *

I acknowledge

I understand that I may request and obtain a copy of this agreement. *

I acknowledge

Date *

MM

DD

YYYY