I hereby request and consent to the performance of hot stone massage on me (or on the client named below, for whom I am legally responsible) by the massage therapist named above and/or any other massage therapist who now or in the future treat me while employed by, working or associated with or serving as back-up for the massage therapist listed above, and by any other massage therapist working at the facility listed above or any affiliated facility, whether signatories to this form or not.

I understand that hot stone massage involves heating stones, then using those stones during the course of massage, either by the massage therapist placing those stones on me to warm and relax muscles or by the massage therapist holding those stones in their hands and then massaging me with those stones.

I have been informed that hot stone massage is a generally safe method of massage, but that it may have some side effects, including, in particular, burns and or related scarring as a result of the contact of the hot stones with my skin. I understand that even with proper care by the massage therapist, it is nearly impossible to predict the precise manner in which a stone will retain heat when warmed and dissipate heat when placed in contact with the body. Variations in this heat transfer process could result in an unexpectedly high rate of heat transfer, and subsequent tissue damage. Further, the visual evidence that a burn is developing typically does not occur until after tissue damage has already happened. Even when both the massage therapist and the client are diligent, conditions leading to burns may still go unnoticed until after the burn has already occurred.

In addition, I understand that a variety of medical conditions which I might have, and which my massage therapist has neither the training, nor the legal right to interpret, could increase the risk of burns for me. For example, I realize that if I have diabetes or any other condition that reduces circulation, the risk of burns is substantially increased. Reduced circulation may limit the ability of the body to properly dissipate heat from a specific location, which could result in a burn. Limited circulation may also result in reduced sensitivity to the presence of heat. Without my input that a stone is too hot for my skin, the massage therapist may have no reasonable way of knowing that there is a problem before it is too late, and a burn has occurred.

I understand that another condition that impacts the risk associated with burns is the sensitivity of my skin type to burns and scarring. I understand that my massage therapist is not trained as a dermatologist or a medical doctor and as such is not trained to reliably interpret the type of skin I have using a Fitzpatrick Scale or any other scientific measure. I understand that if I have a Fitzpatrick Scale Skin Type VI, that my skin is more sensitive to burns, and I should be particularly mindful to communicate with my massage therapist if I experience any discomfort from heat. However, I realize that even if my massage therapist and I are both diligent, the risks of burns associated with Skin Type VI may be unavoidable. Further, I realize that if I am Skin Type I, while I am not as sensitive to burns, once I am burned, my skin is likely to scar easily, which may leave me permanently disfigured. I understand that if I am Skin Type VI, there is an unavoidable risk of scarring associated with a burn, which might otherwise have no permanent effect on other people.

Finally, I understand that certain medications make a person more sensitive to heat exposure. I realize that it is my responsibility to consult my doctor to determine if any of the medications I am taking could cause me to be more heat sensitive, and if so, to inform my massage therapist of the medication(s) and the doctor’s recommendations pertaining to the application of heat to my skin.

I understand that while this document describes the major risks of hot stone massage, other side effect and risks may occur. I do not expect the massage therapist to be able to anticipate and explain all possible risks and complications of hot stone massage. I wish to rely on the massage therapist to exercise judgment during the course of hot stone massage, which at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to hot stone massage, have been told about the risks and benefits of this modality, and have had an opportunity to ask questions. I intend this consent form to cover current and future hot stone massage therapy provided to me as indicated in paragraph 1 above.