Prenatal Massage Liability Release JotForm

Prenatal Massage Liability Release Form

Utah Pregnancy Massage Care
Basic Info & Consent
Name*

First NameLast Name
Your Birthdate*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Email*
example@example.com
Where did you originally hear about Utah Pregnancy Massage Care? (Google, Social Media, a friend, etc?)
Current number of weeks pregnant:*
Your Answer
Due Date:*

MonthDayYear
Date
You are currently pregnant with:*

One babyTwinsTripletsNot sureOther
Current Medications (if any):
Your Answer
Do you have any topical allergies to the following? (Please write in any other allergies in the "Other" box below.)*

Coconut OilJojoba OilGinger OilNone of the aboveOther
Your Licensed Massage Therapist will plan on massaging the following areas: back, hips/glutes, legs, feet, hands, arms, and head/neck. Are there any areas you do NOT want massaged?*

Nope! A full body massage sounds great!Other
Would you like your belly/abdomen gently massaged?*

YesNo
What are you hoping to accomplish at your massage appointment?*

General relaxationHip pain/lower back reliefNeck/shoulder pain reliefHeadache/migraine reliefOther
Is there anything you'd like your massage therapist to know about (illness, morning sickness, specific requests, specific pain you are dealing with)?
Would you like to include any of the following $5 Add-Ons to your massage?*

Collagen Eye MaskHot Towel & Hydration Foot WrapMagnesium Muscle Treatment-$5 per area (typically calves or lower back)No thanks
You can also request a complimentary add-on when you arrive at your appointment including: ginger essential oil, citrus essential oil, or Vitamin E oil on abdomen/belly.
Do you give permission to your Licensed Massage Therapist to do a prone/supine (face-down/face-up) massage with modified pregnancy bolstering? PLEASE SELECT YES OR NO*

YesNo
Utah Pregnancy Massage Care does not require you to wear a face mask during your massage. Your Massage Therapist will comply to whatever you feel comfortable with. Do you prefer your Massage Therapist to wear a face mask during your massage?*

YesNo
Do you have an e-Gift card or a Coupon for this appointment? (Please write the name of who the e-Gift card or Coupon is from.)
If you were not able to schedule your ideal appointment time, please write below the best day(s) and time(s) for you and you will be put on the cancellation list:

No thanks, I like the appointment time I haveOther
Contraindications:
Massage therapy during pregnancy has been shown to be beneficial for a number of reasons such as, but not limited to, alleviating musculoskeletal pain, reducing stress/cortisol levels, improving circulation of blood & lymph flow, and helping to reduce fatigue. However, there are risks associated with specific conditions that may occur during pregnancy.

You must inform your massage massage therapist if you have any of the following conditions or symptoms which may make massage therapy during pregnancy a risk factor (section 1) OR a contraindication (section 2) and may require your massage therapist to postpone or alter the massage (please check all that apply in both sections).
SECTION 1: RISK FACTORS (check all that apply)

*massage will need to proceed with caution, or be altered*:
Any Cardiac, Pulmonary, Liver, or Renal disorders? (massage may need to be postponed)
Please Specify
Any other complications, symptoms, diseases, or concerns that your massage therapist may need to know about? (massage may need to be postponed)
Please Specify
SECTION 2 CONTRAINDICATIONS (check all that apply)

*massage will need to be postponed (unless an official, approved written note from your doctor is presented)* :
I, insert your full name here * , have read the aforementioned
conditions and symptoms which could make massage therapy during pregnancy recovery contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed all risk factors of my pregnancy.

I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy. I agree that my healthcare provider/physician has given me clearance to receive massage therapy.

I understand the information contained on this form and confirm that (1) I am receiving medical care including regular check-ups with a licensed healthcare provider. (2) I have listed all of my symptoms, conditions, and/or complications. (3) I am not currently experiencing any of the listed symptoms, conditions, or complications that are contraindications (section 2) of pregnancy massage.

I give permission and understand that I will be receiving massage therapy as an adjunct form of healthcare only, and that this therapy is not meant to replace appropriate medical care. I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so he/she may adjust accordingly. I understand that I or the massage therapist may terminate the session at any time.

I release the massage therapist/practitioner of all liability for any harm to me or my fetus(es), including miscarriage, preterm labor, or any other complications that may unintentionally occur during or after my treatment(s).
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Date

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Date
Policy Notification

Utah Pregnancy Massage Care appreciates that you’ve chosen us for your prenatal and postnatal massage needs. To provide the best service possible to our clients, we have implemented the following policies.
Late Arrival Policy

We understand that issues can arise that may cause you to be late for your appointment. However, we ask that you call to inform us if this ever occurs so we can do our best to accommodate you. Appointment times are reserved for each client, so oftentimes we cannot exceed that reserved time without making the next client late. For this reason, arriving after your appointment time may result in loss of time from your massage so that your session ends at the scheduled time. Full service fees will be charged even when sessions are shortened due to late arrival. In return we will do our best to be on time, and if we are unable to do so we will add time to your session to make up for our late arrival or adjust the service charge accordingly.

No-show/Late Cancellation Policy

We respectfully ask that you provide us with a 24 hour notice of any schedule changes or cancellation requests. Please understand that when you cancel or miss your appointment without providing a 24 hour notice we are often unable to fill that appointment time. This is an inconvenience to your therapist and also means our other clients miss the chance to receive services they need. For this reason, you will be charged 50% of the service fee for the first missed session and 100% of the service fee for each missed session after that. We also reserve the right to require a credit card number to be given to book future appointments so that appropriate fees may be charged if a late cancellation or no-show does occur.

Inclement weather may also result in the need for late cancellations. We will do our best to give advanced notice if we are closing or need to cancel due to bad weather and we ask you to do the same. Please do not risk your own safety trying to make your appointment. Late cancellation due to emergency, illness, or inclement weather will generally not result in any missed session charges, but this is determined on a case-by-case basis.

By signing below, you agree to abide by these policies.
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Prenatal Massage Liability Release Form

Basic Info & Consent

Contraindications:

Policy Notification