Breast Massage Consent Form

(Sensitive Area Treatment – In Accordance with CMTO Standards of Practice)

Purpose of This Consent

Breast massage is considered a sensitive area treatment under the College of Massage Therapists of Ontario (CMTO). Your informed, voluntary consent is required before any treatment can begin. This form explains the purpose, benefits, risks, draping procedures, and your rights as a client.

Reason for Breast Massage

Breast massage may be indicated to address:

muscular tension or pain in the chest, upper back, or shoulder region

lymphatic congestion

postural imbalance

scar tissue, adhesions, or restricted mobility

discomfort related to pregnancy, breastfeeding, or chest wall dysfunction

therapeutic goals connected to overall treatment planning

Description of Treatment

Breast massage may include manual techniques applied to:

breast tissue

chest wall muscles

pectoral region

rib attachments and fascia

Treatment will only be performed with appropriate draping. At no time will nipples be exposed unless specifically required for therapeutic purposes and only with your explicit consent.

You may choose one of the following draping options:

Your Rights

• Consent is voluntary and may be withdrawn at any time, verbally or in writing.

• You may ask questions at any point during treatment.

• You may request modifications to positioning, draping, or techniques.

• Declining breast massage will not impact your access to other therapeutic care.

Potential Benefits

• reduction in muscular tension or pain

• improved mobility of chest and shoulder region

• enhanced lymphatic flow

• support for postural balance

• improved breathing mechanics

Potential Risks

• temporary tenderness or soreness

• emotional discomfort due to sensitive nature of treatment

• mild bruising (rare)

• temporary increase in symptoms as tissues respond to treatment

All techniques will be performed within your comfort and tolerance levels.

Therapist Responsibilities (Gurwinderjit Singh Rubal Reg# T964)

Your therapist will:

• clearly explain each step before touching any sensitive area

• maintain professional boundaries at all times

• ensure proper draping according to CMTO Standards

• stop or modify treatment immediately if requested

• record your consent in your health record as required

Client Consent

I, have read and understood the information above. The therapist has explained the purpose, nature, benefits, risks, and options related to breast massage. All my questions have been answered to my satisfaction.

I voluntarily consent to receive breast massage as part of my treatment plan.

© Vaid Rubal’s Clinic Ltd., Brampton, Ontario. This confidential document is maintained as part of the client record and is the property of the clinic, in accordance with professional and regulatory requirements.