Informed Consent Form

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offered by raphaël beaupied, certified practitioner


Please carefully read all the points listed below

The informed consent form aims to address important subjects, clarify expectations, and to state any disclaimer that Ayurvedic Yoga Massage/Dynamic Thai Massage therapy involves. Please carefully read all the points listed through the form and sign it to give your consent to receive an Ayurvedic Yoga Massage/Dynamic Thai Massage therapy.

Informed Consent Form
– I (Client) have chosen to consult with Kůra Růka and hereby give consent for Ayurvedic Yoga Massage/Dynamic Thai Massage therapy (Therapy, Massage therapy) to be provided by Raphaël Beaupied (Therapist, Massage therapist) who I understand is a practitioner accredited by the ARYM Institute (Mysore, India) and Blue Garden (Chiang Mai, Thailand).

– I have filled the required massage intake form and do not expect the massage therapist to have foreseen any previous or pre-existing medical condition that I have not mentioned.

– I understand that massage therapy may provide benefits for certain conditions but that lasting results are not guaranteed. These benefits may include relief of muscular tension, relaxation, reduction in the symptoms of stress-related conditions and provision of general wellbeing.

– I also understand that massage therapy may produce expected side effects such as muscle soreness, increase awareness of areas of pain and light-headedness amongst other possible temporary outcomes.

– I acknowledge that the massage therapist cannot diagnose, treat or prescribe any type of physical or mental conditions nor can the services provided be a substitute for consulting with a licensed physician or other health care professional.

– I understand that relevant body parts will be draped accordingly during certain sections of the therapy to ensure that there is no indecent exposure.

– I understand that I may experience emotional releases, intestinal gas or eructations during the therapy, which are a natural, normal response from the body.

– The massage therapist understands that I have the right to question procedures used and to receive an explanation of any manipulations that the therapist performs.

– I will inform the therapist about any discomfort I may experience during the session and understand that the massage therapy will be adjusted accordingly. I am informed that I have the right to terminate the therapy at any time if such discomfort persists.

By signing this form, I confirm having carefully read and understood the points stated above and therefore give my consent to receive Ayurvedic Yoga Massage/Dynamic Thai Massage from Kůra Růka’s massage therapist Raphaël Beaupied.*

Sign by entering your full name below followed by today’s date*


Privacy policy

Kůra Růka is committed to the privacy of its clients. Personal information is treated as confidential and is used only for the purpose for which it was collected. Information kept on file will not be released to a third party without the express consent of the client or as required by law.

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