Client Intake & Consent

Prenatal Massage Client Intake Form

All information is held in confidence. At no given point is information disclosed or shared without client’s written consent.

Full Name*

First NameMiddle NameLast Name

Date*

MonthDayYear

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

E-mail*

Emergency Contact*

Phone Number*

Occupation

Medications*

Allergies*

Prenatal Intake and Health History

1. In what week of pregnancy are you?*

2. What discomforts, pain, or other needs are you hoping to have addressed with massage therapy?*

3. Frequency - please select the most accurate*

4. Are you regularly seeing a physician, nurse-midwife, or midwide? Please provide name and phone number.*

5. Do you have any medical conditions? Please check those that apply.*

6. Have you had any complications or problems with this pregnancy? Please check those that apply:*

7. Are you currently experiencing any infection or disorder? Please check those that apply.*

8. Please list any recent injuries, surgeries, rash, illness, or open wounds.*

9. Have you ever received therapeutic massage for a specific problem or injury?

Massage Policies:

• Client services and chart information are confidential. Written authorization is required to release any information.
• Your scheduled session time is set aside for you. If you are unable to keep your scheduled appointment, please inform Britain Schroeder, LMT LLC 24 hours prior to time of service. Same day cancellations will result in a 100% charge for price of service.
• Britain Schroeder, LMT LLC will arrive 10-15 minutes prior to scheduled appointment time for set up and treatment plan discussion.
• Britain Schroeder, LMT LLC offers professional and therapeutic massage therapy. There is a zero tolerance policy for inappropriate behavior. If instance occurs, Britain Schroeder, LMT LLC reserves the right to end service, collect payment, and prosecute to the full extent of the law.
• I understand that my therapeutic massage therapist or I may end the session at any time for any reason.

Client Agreement:

I understand that therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, or pharmaceuticals. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service. It is my choice to receive therapeutic massage as a form of therapy. I understand that treatment given is designed to address the care and prevention of myofascial pain and dysfunction. I also undersand that at any time I feel pain or discomfort during the session, I will immediately inform my therapeutic massage therapist so they adjust. I have stated my pertinent medical conditions, and will update the massage therapist of any changes in my health status. I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Britain Schroeder, LMT LLC from any liability whatsoever arising from receiving massage therapy services. By my electronic signature below, I agree to the massage policy and client agreement above.

Date*

Signature*

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.