Elle Marie Spa: Massages (Including Prenatal) Waiver

Date *

Date

Name *

First Name Last Name

Date of Birth *

Date

Email *

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

How did you hear about us?

Walked by Facebook/Instagram Online Search Referral

If referred, by who?

Have you has a professional massage before?

What kind of massage are you seeking

Therapeutic/Deep Tissue Relaxation

What pressure do you prefer

Light Medium Deep

Have you experiences any of these health conditions in the past or present?

Any allergies? Please explain.

Any areas you do not desire to be massaged on? Please explain.

Which areas would you like to focus on today?

PRENATAL MASSAGE RISKS & BENEFITS
Prenatal Massage Therapy Benefits - There are several observed or identified potential

benefits to massage therapy during pregnancy, including:

Relieves muscular tension, especially in the lower back, upper back, shoulders and neck
Reduces stress on weight-bearing joints
Enhances body awareness for better posture and less discomfort

Assists with body mechanics and movement during structural change Supports birth process by relaxing muscles involved in labor and birth Eases anxiety and stress during time of transition
Provides emotional support and nurturance

Prenatal Massage Therapy Contraindications – Performing massage therapy during pregnancy is contraindicated for women experiencing any of the following symptoms/signs:

Bloody discharge
Continual abdominal pains
Sudden gush or leakage of amniotic fluid
Sudden, rapid weight gain
Increased blood pressure
Protein or sugar in urine
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
Increased urination in the second trimester
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.

Prenatal High-Risk Pregnancies

It is a strict policy of Beyond Exercise to require a doctor’s release form in order to receive massage therapy during a 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

Are you pregnant or breast-feeding?

YES NO

Did you read the above benefits and risks?

YES NO

Are you experiencing any of the risks as outlined above?

YES NO

Do you consent to us performing a massage at this time for you?

YES NO

Conversation preferences

I prefer to discuss my goals during our treatment and be informed of what you’re applying to my skin. I prefer to relax and keep conversation to a minimum.

I acknowledge that I must adhere to Elle Marie Spa's policies:

Cancellations: We allow cancellations 24 hours prior to your appointment. Cancellations less than 24 hours will result in a 50% charge and a No Show will result in a 100% charge on your gift card or credit card.

Check In: Please check in at least 10 minutes prior to your reservation. If you arrive late for your appointment, you risk having your appointment shortened so that we can accommodate the next scheduled guest.

Gratuities: The price of your service does not include gratuity. We recommend a 15% to 20% gratuity for your service provider.

We thank you in advance for respecting these and look forward to making your day amazing!

I agree

Signature

Clear

Elle Marie Spa

Your History

For our pregnant guests,

Your Service

Your Promise