Contact Information

Prenatal Intake

Prenatal massage offers several potential benefits, including muscular tension relief, stress reduction on weight-bearing joints, supporting the birth process by relaxing muscles involved with labor, and easing stress/anxiety. We're looking forward to treating you!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Mobile Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Best email address to reach you*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number

What trimester are you in today?*
Due Date:*

MonthDayYear
Have you been told that your pregnancy is considered to be high-risk?*

YesNo
Please describe high-risk reasons below:*
Have you had any problems or complications in this pregnancy?*

Yes, I've had problems or complications.No, I've not had problems or complications.
Please describe problems or complications below:*
Receiving prenatal massage is contraindicated for women experiencing any of the following symptoms/signs:
- Blood loss/ discharge
- Continual abdominal pains
- Sudden gush or leakage of amniotic fluid
- Sudden, rapid weight gain
- Increased blood pressure
- Severe back pain that does not subside with change in position
- Visual disturbances
- Severe nausea and/or vomiting (cannot keep anything down)
- Severe headaches
- Excessive hunger and thirst
- Fever
- Diarrhea
- Excessive swelling in arms or legs
- Decrease in fetal movement over a 24-hour period
- Additional conditions – phlebitis, thrombosis, or suspected clotting conditions, any kidney, liver or spleen compromise or infection. Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.
For our clients’ safety, we require a doctor’s release form in order to receive massage therapy during any high-risk pregnancy, which includes, but is not limited to:
- Early labor, miscarriage threat, placental or cervical dysfunction
- Gestational Edema Proteinuria Hypertension (GEPH)
- Preeclampsia
- Gestational Diabetes
- Pre-existing cardiac, renal, connective tissue or liver disorders/diseases
- Fetal genetic disorders
- Complications in previous pregnancies
- Three or more miscarriages
We also require a doctor’s release form in order to receive massage therapy during the first trimester.

Please read and sign below, to continue with treatment:

I understand that massage therapy is a health aid and does not take the place of a physicians’ care. Any information exchanged during a massage session is confidential and is only used to provide the best massage care. If I am having or develop any complications, I will discuss with my massage therapist.

I hereby voluntarily release B In Touch Massage Therapy and its therapists from any liability should my condition be aggravated at any time. By signing below, I agree that I have read the information above and have decided to receive a prenatal massage at my own risk.

I have received and understood the information on these pages about the benefits and possible contraindications of massage therapy during pregnancy, and confirm that:
- I have not experienced any the complications or conditions listed.
- I am receiving medical care including regular check-ups throughout my pregnancy.
- I AM experiencing a high-risk pregnancy or have decided to have a 1st trimester massage, but have given a doctor’s release form to my massage therapist.
I have received and understood all of the above information.*

I understand.
Signature*
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Prenatal Intake