Prenatal Consent

Prenatal Consent

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Name*

First NameMiddle InitialLast Name
Due Date*

MonthDayYear
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Are you at least 13 weeks or in our 2nd Trimester of gestation? *
Is your pregnancy considered high-risk? If yes, please provide your doctor's written consent.*
Emergency Contact*

First NameLast Name
Phone Number
Prenatal Care Provider*
Phone Number
Health History

Please complete the fields below if anything else applies. Current or Past
Medications/ Other medical conditions:
Allergies/ Skin sensitivities:
Please describe any issues, complications, or problems with this pregnancy.
Will there be anything else you would need during your session to make you more comfortable?
4 the Luv of Massage Day Spa Terms and Conditions:

Client services and chart information are confidential.

Written authorization is required from you to release any information.
- I have completed this consent form to the best of my knowledge.
- I understand that massage does not have the place of any physician's treatment or care.
- I understand that I may also end the session at any time if I feel uncomfortable for any reason.
- I hereby release 4 the Luv of Massage Day Spa employees, owners, representatives from all claims, costs, demands, expenses and causes of action should any condition be aggravated at any time.
By my electronic signature below, I agree that I have read the information above and have decided to receive a prenatal massage at my own risk.
Signature

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

MonthDayYear
Date
Should be Empty:

Prenatal Consent

Health History