LAB 1

INFORMED CONSENT

AMANDA HAMMOND
STUDENT#34114665
INTRO TO MASSAGE THEORY AND
TECHNIQUES
ALEXANDRE TOKAREV
NOVEMBER 27, 2023
Hello Mrs. Smith,

After my assessment and the review of your health history, I have created an initial treatment plan,
which I would like to discuss with you. The goals and benefits of the treatment plan are to reduce stress,
initiate relaxation, and help you become more aware of where you may have any tension or discomfort.
According to the information you have provided in your health history and my assessment, I do not
believe there are any contraindications to this massage treatment.

Treatment Plan

 Each session of your treatment plan will be 1 hour in length. The cost of the treatment is $100
per session (60 minutes).
 Once I leave the room, I ask that you remove as much of the clothes as you are comfortable
doing, leaving your underwear on.
 I will then ask that you climb up on the table, lying face down between the sheets and cover
yourself with the top sheet. Will you need my assistance getting up onto the bed?
 You will start by laying on the massage table, face down, with your face in the face cradle. I will
place 2 pillows under you, if desired, for your comfort – 1 under your ankles and 1 under your
stomach.
 You will be covered with a sheet at all times and only the treated area will be exposed.
 I will be working on your back, shoulders, neck, and the back of your legs. Only the area being
treated during that time will be undraped. Are you comfortable with these areas being treated
on or would you like me to avoid any areas?
 After we complete the back treatment, I will remove the pillows, hold the sheets secure and ask
you to turn over onto your back and move down in the bed so your head is below the top of the
bed, not resting your head on the face cradle. I will then replace the pillows under your head and
knees.
 I will then treat the front of your legs and feet, abdomen, arms, hands, head, neck, and
shoulders. Are you comfortable with these areas being treated or would you like me to avoid any
areas?
 The treatment will include warm hydrotherapy, a series of massage techniques - applied with my
hands and forearm, and passive stretching, as tolerated.
 I will be working within your pain tolerance, remembering 0 is no pain, 10 is the worst pain you
have ever felt. Please let me know at any time if the pressure is causing you any pain or
discomfort.
 I will be constantly checking in for your level of comfort to the different massage techniques and
pressure.

There are no contraindications and I do not see any possible risks associated with the treatment plan,
however, there are possible risks associated with the treatment plan.

You may experience some side effects of the massage after the treatment. These include dizziness when
returning from the lying position to sitting. You may also experience muscle tightness and tenderness or
soreness in the muscles treated the following day or two. This should disappear about 24 hours after
treatment. A warm shower or heating pad may help alleviate the pain.
At any time during the treatment, you can ask me to stop or modify the treatment, based on your
comfort level.

I anticipate that your condition will be improved, and you will feel much better by the end of our
treatment plan.

Do you have any questions at this time?

Consent to treatment

Now that I have an idea of our treatment plan, Mrs. Smith, I would like to discuss with you the future
treatment plan. I am recommending that we start with 1 - 60-minute session each week for the next 6
weeks. During each session, we will work on the same areas of the body as today – your feet, legs, back,
shoulders, neck, head, abdomen, arms and hands. You will always remain draped with the sheet, and
only the area being treated will be exposed. You will be lying face down with a pillow under your ankles
and stomach, if desired for comfort, and your face in the face cradle for the first part of the treatment.
You will then lie on your back, with a pillow under your knees and head for the second part of the
treatment. Each session, I will work within your pain tolerance level and comfort and will constantly
check in with you on your comfort. Please remember that the pressure can be adjusted or stopped at
any time for your comfort, even in the middle of the treatment. At the end of the 6 weeks, we will assess
your condition and how you are responding to the treatments.

The benefits of this treatment plan are to reduce stress, help you to relax and become more aware of
where you may have any tension or discomfort, and to help relieve that tension or discomfort.
Combined with the treatment plan I have developed, I will also be providing you with some remedial
exercises – including some self-massage techniques, hydrotherapy applications of heat, and some light
stretches and range of motion exercises to do at home independently. These will compliment the
treatments you receive in office and help increase the relaxation effects of this treatment.

Again, I want to remind you that there are some mild side effects that you may experience after your
treatments. These include dizziness or light-headedness] immediately after your treatment – when
returning from a lying to sitting position. Please remember to take your time when getting up. You may
also experience muscle tightness and tenderness or soreness in the muscles treated. A warm shower or
heating pad may help with this and should subside within 24 hours.

Always remember you have the right to ask me to stop or modify treatment at any time. It is my
anticipation that you will feel less tension and significantly more relaxed after our first 6 weeks of
treatment.

Thank you for taking the time to discuss the treatment plan with me. Do you have further questions
before we begin, Mrs. Smith?

Do I have your consent to begin with this treatment plan?