Prenatal first trimester waiver
Name
*
First Name
Last Name
Email
*
example@example.com
Cell phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pregnancy Due Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of your appointment at B In Touch Massage Therapy
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is your pregnancy considered "high risk"?
*
Yes
No
If yes, please explain:
Please sign below to indicate your knowledge of the risks involved with receiving a prenatal massage during the first trimester, and that you knowingly receive treatment at B In Touch massage Therapy without clearance from your physician, removing B In Touch Massage Therapy of any liability involved with proceeding.
*
Submit
Should be Empty: