Prenatal Massage Release Form

Prenatal Massage Release From:

Prenatal Massage has been shown to be beneficial for a number of common complaints such as fatigue, musculoskeletal pain, sciatica, edema, and many others. There are contraindications associated with specific conditions that may occur during pregnancy. You must inform your massage therapist if you have or have had in the past any of the following conditions or symptoms.
Full Name*

First NameLast Name
Address*

Street Address

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Email*
example@example.com
Phone Number*

Area CodePhone Number
Babies Due Date*

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Date
Referred By*
Please list areas of discomfort you would like addressed during this session.
Please select the following health conditions you have

High or Low Blood PressureDiabetesHistory of miscarriagePreeclampsiaHistory of high-risk pregnancyDrug exposureMultiplesPitting edemaEpilepsy or other convulsive disordersAbdominal painBloody dischargeFeverSudden edema/swellingDecrease in fetal movement over 24-hour periodHeadachesSevere nausea or vomitingNone of these apply to meOther
Please read the following and sign your name after reading each item below about your massage session.
I have read the aforementioned conditions and symptoms which make massage therapy during pregnancy contraindicated. The massage therapist has discussed this information with me and provided opportunity to ask quesitons. I have disclosed all high risk factors of my pregnancy. I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy during pregnancy. I understand that I will be receiving massage therapy as an adjunct from of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist from all liability for any harm that may unintentially occur during my treatment(s).
Please Sign and Date this form confirming you agree to the above statements.*

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Date*

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Prenatal Massage Release From: