Pregnancy Massage Consent & Liability Waiver
Complete your details, pregnancy and health history, and acknowledge risks, benefits, and that massage is not medical care.
Client Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How many weeks pregnant are you?
*
Have you experienced any complications during this pregnancy (e.g., preeclampsia, bleeding, high blood pressure)?
*
No
Yes (please specify below)
If yes, please specify your pregnancy complications.
Do you have any of the following conditions? (Select all that apply)
High blood pressure
Gestational diabetes
Preterm labor risk
Placenta previa
Blood clotting disorders
Other (please specify below)
If other or additional health conditions, please specify.
Please list any medications you are currently taking.
Client Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Waiver
Submit Waiver
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