Prenatal Massage and Bodywork

Prenatal Massage and Bodywork

Intake Form
Client Information
Name*

First NameLast Name
Parent's Name (if under the age of 18)

First NameLast Name
E mail:*
example@example.com
Date of Birth

MonthDayYear
Address*

Street Address

CityState

Zip Code
Phone Number*

Area CodePhone Number
Current Occupation:
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Were you referred to Anointed Hands?*

YesNo
If yes, by whom?
Massage and Bodywork Questions
Have you ever received professional massage and bodywork?*

YesNo
If yes, how often do you get massages?
Please describe any exercise or movement you do each week.
Health Questions
Please specify any areas of your body affected by injury, ailment or surgery.*
Any medications, vitamins or supplements?*
Pregnancy Questions
Prenatal Care Provider Name*

First NameLast Name
Prenatal Care Provider Phone Number*

Area CodePhone Number
Does Anointed Hands have permission to contact your Care Provider?*

YesNo
It is our intention to provide you with a safe and nurturing experience during your pregnancy. There are some conditions we need to be aware of in order to modify our treatment in the best interest of you and your baby. It is our policy to work with a pregnant woman only if her primary healthcare provider has approved this treatment.
My Due Date*

MonthDayYear
Date
How many weeks pregnant are you?*
Any current issues related to this pregnancy?*
Anything else you would like me to know?
Liability Waiver and Agreement
- I verify that my birth care doctor is aware and approves of me receiving massage therapy during my current pregnancy.
  I have informed Anointed Hands of any complications related to my pregnancy.
- I understand that Anointed Hands has the right to refuse service if the therapist believes any of my symptoms are contraindicated for receiving massage therapy.
- I understand that I will be receiving massage therapy and bodywork as a form of adjunctive health care only and that the massage therapy I receive is not a substitute for obstetric prenatal or perinatal care from a medical doctor or other licensed provider.
- I understand that massage therapy is provided for stress reduction, relaxation, relief from muscular tension, and improvement of circulation and energy flow.
- If I experience pain or discomfort during the session, I will immediately inform my therapist so that pressure/strokes can be adjusted to my level of comfort.
- I will not hold my therapist responsible for any pain or discomfort I experience during or after the session.
- I affirm that I have notified my therapist of all known medical conditions and injuries.
- I agree to inform the therapist of any changes in my health and medical condition.
- I understand that there shall be no liability on the therapist’s part should I forget to do so.
- I understand that massage is entirely therapeutic and non-sexual in nature.
- It is my choice to receive massage therapy, and I give my consent to receive treatment.
- By signing this release, I hereby waive and release my therapist and Anointed Hands Massage Therapy LLC from any and all liability, past, present, and future relating to massage therapy and bodywork.
- I verify that my birth care doctor is aware and approves of me receiving massage therapy during my current pregnancy.
- I have informed Anointed Hands of any complications related to my pregnancy.
- I understand that Anointed Hands has the right to refuse service if the therapist believes any of my symptoms are contraindicated for receiving massage therapy.
- I understand that I will be receiving massage therapy and bodywork as a form of adjunctive health care only and that the massage therapy I receive is not a substitute for obstetric prenatal or perinatal care from a medical doctor or other licensed provider.
I have read the statement above and agree with all the policies.*

I agreeI disagree
Today's Date:*

MonthDayYear
Should be Empty:

Prenatal Massage and Bodywork

Client Information

Massage and Bodywork Questions

Health Questions

Pregnancy Questions

Liability Waiver and Agreement