Pregnancy Massage - Informed Consent Form
EB Massage & Wellbeing
Full Name
First Name
Last Name
DOB
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Month
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Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
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Area Code
Phone Number
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
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Area Code
Phone Number
Reason for booking your appointment/particular areas of discomfort:
Due Date (if known)
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Month
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Day
Year
Date
Pregnancy Massage Treatment - Procedure Explanation
Informed consent
I understand my pregnancy massage treatment may include (please tick):
An initial consultation explain the treatment and what it involves to ensure comfort.
Gentle massage techniques avoiding deep tissue work - such as effleurage, light petrissage, gentle strokes and lymphatic drainage.
Positioning in the side-lying position for comfort and safety
Potential risks and side-effects
Communication with the therapist to engage in feedback regarding my levels of comfort and massage pressure, etc.
Referral to other professionals if my condition needs additional assessment or specialist treatment.
Pregnancy Massage Treatment - Client Communication
Informed consent
I acknowledge (please tick):
That I've been given ample opportunity to ask questions concerning my treatment, the process involved, and I am satisfied with the answers provided.
Pregnancy Massage Treatment - Explicit Consent
I understand and acknowledge (please tick):
The nature of sports massage therapy and agree voluntarily to undergo treatment.
That I may withdraw or modify my consent at any time.
Signature
Date
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Month
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Day
Year
Date
Pregnancy Massage Treatment - Ongoing Consent & Documentation
I understand that (please tick):
My therapist will regularly communicate with me to ensure I'm comfortable and am consenting throughout the session.
The personal information I have shared, and my treatment records will be securely stored and accessed only be relevant and authorised professionals.
Contraindications checklist
Please tick where applicable to inform your therapist if you currently have, or have had in the past six months, any of the following symptoms/conditions:
Musculoskeletal issues
Sprains/strains/fractures
Myositis/tendonitis
Joint replacement
Arthritis/osteoporosis/bursitis
Please specify:
Circulatory issues
Heart condition/hypertension/hypotension
DVT/phlebitis/varicose veins
Haemophilia/CV disease
Stroke/TIA
Please specify:
Neurological issues
Epilepsy
Sciatica/neuralgia
MS
Parkinson's
Please specify:
Skin issues
Eczema/acne/dermatitis/psoriasis
Athlete's foot/warts
Impetigo
Cuts/bruises/burns
Undiagnosed lumps
Please specify:
Respiratory issues
Asthma
Pneumonia
Bronchitis/sinusitis
Cold/cough/flu
Please specify:
Immune issues
Cancer
Rheumatoid arthritis
HIV
AIDS
Please specify:
Digestive issues
IBS/constipation/diarrhoea
Gall stones/kidney stones
Urinary tract infection
Please specify:
Miscellaneous
Diabetes/Gestational Diabetes
Abdominal Pain
Back Pain
Morning Sickness
Heartburn
High risk pregnancy
Vaginal bleeding or spotting
SPD
High Blood Pressure
Obstetric Cholestasis
Placental Dysfunction
Pre-Eclampsia
Eclampsia
HELLP Syndrome
Unstable pregnancy
Allergies
Glandular fever
Headaches
Psychological issues
Substance abuse
Feeling unwell
Recent and/or major operations
Please specify:
Are you currently under the care of a healthcare provider for your pregnancy?
Yes
No
Have you been given permission by a medical professional to carry out this appointment?
Do you have any pregnancy-related complications or medical conditions?
Have you had any previous pregnancy-related complications?
Yes
No
Please list any medications you are currently taking:
Declaration:
I fully understand that thorough and honest responses to these questions are essential for my safety. I hereby confirm the information I have shared is accurate and I have disclosed all relevant medical conditions. I understand the safety and effectiveness of my treatment is reliant on honest communication and I understand its importance.
Client signature
Date
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Month
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Therapist signature
Date
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Month
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Date
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