Postnatal Massage Intake Form

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Format: (000) 000-0000.

In case of emergency, we will contact the person below:

Emergency Contact Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Relationship

OB/Midwife Name

First NameLast Name

OB/Midwife Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Most recent Baby’s Birthday! 🥳

Date

Type of delivery

Are you currently nursing?

Have you ever received a professional massage?

Is this your first massage post-delivery?

What type of pressure do you prefer? (light, medium, firm, deep, mix of any, etc.)

Number of pregnancies in your life?

Only if you are willing to share! :)

Number of births in your life?

Only if you are willing to share! :)

Please give any details about your labor and delivery you’d like to share, totally optional!

How has this postpartum been for you so far?

Do you have any allergies?

If yes, please specify on the field above.

Please list any current medications

What is your goal for the session? (relaxation, muscle pain relief, reduce postpartum swelling, etc.)

Do you have any current musculoskeletal injuries?

Please list any surgeries or major injuries you have had in your lifetime here:

Current medical conditions like Diabetes, High Blood Pressure, other Heart conditions, Postpartum Depression/Anxiety, Kidney conditions, Epilepsy, Scoliosis, any communicable disease, etc.?

How did you hear of us?

Please review and accept:

I acknowledge that I am responsible for 50% of the session price if the cancellation is within 24 hours of my appointment, and 100% of the session price if I am late, or do not show up. My appointment begins at our scheduled time regardless of if I am late or not. If I am more than 15 minutes late to my appointment I understand that it may be cancelled, and I will be charged 100% of the session price.I understand that massage therapy is for the purpose of stress reduction, relief from muscular discomfort and for increasing blood, lymph, and energy circulation. I further understand the massage therapist does not diagnose illness, disease, or any other physical disorder. As such, the massage therapist does not prescribe medical treatment, medication(s), and does not perform spinal manipulation. By signing below, I further agree that I will not hold the massage therapist or its affiliates responsible should there be any unfavorable outcome or result.

Please review and accept only if applicable:

By signing below, I acknowledge that I have fully read and completely understand the above statements, and that I have answered every section truthfully.

Date Signed

Date

Honest Energy

Basic Info

Emergency Contact Details

Health Info

Consent and Waiver