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Prenatal/Postpartum Client Intake Form
This form will take 10-15 minutes to complete. It is secure and confidential to Portland Prenatal Massage only. Please complete it at least 24 hours before your scheduled massage session.
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    (i.e. 07/23/1984)
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    Name & Phone Number
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    Name
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    • Doctor/Midwife (if so who?)
    • Doula (if so who?)
    • Facebook
    • Referral (if so who?)
    • Website
    • Other...
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    Choose as many as you need to
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    Please check any below that apply to you
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    It is extremely important that you let us know if you are experiencing any of the following symptoms/issues, as they may require that we obtain a Physician/Midwife release form prior to your session.
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    A good massage is not so deep that you flinch or tense up, but deep enough that it feels good to you. GENERALLY SPEAKING, on a scale of 1-10, what depth of pressure/intensity feels perfect to you?
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    GENERALLY SPEAKING, Are there any areas you want me to skip entirely, either because you don't like it, or because you want to allocate more time elsewhere? 
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    (I'll make sure NOT to do these things!)
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    (For example: "I really love my feet being worked on!")
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     I have stated all my known medical conditions and take it upon myself to keep my therapist updated on changes to my physical health. I understand that any information exchanged during a session is kept confidential.  If I am currently having or at any future point develop complications or serious conditions during and/or after my pregnancy, I will notify my massage therapist prior to my session, and will have a medical release for bodywork signed by my prenatal care provider before receiving massage therapy I understand that massage therapy given here is for the purpose of stress reduction, relaxation, relief from muscular tension, or for increasing circulation, balance, body awareness and energy flow. I understand that the therapist does not diagnose illness, disease, or any other physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, nor do they perform any spinal manipulations.  I understand that massage therapy is not a substitute for prenatal care, medical examination and/or diagnosis and that it is recommended that I see a physician for any physical ailment and that I have regular prenatal care. CANCELLATIONS/RESCHEDULING: If I am not able to make a scheduled appointment, I agree to cancel or reschedule the appointment AT LEAST 24 hours in advance. I agree to pay $35 or 50% of the full session rate (whichever is greater) if I give less than 24 hours notice. If I am in labor, have a contagious illness, or have a sudden, unplanned health or personal emergency that will cause me to miss my appointment I agree to inform Portland Prenatal Massage immediately, but agree to the pay the cancellation fee unless Portland Prenatal Massage decides to grant an exception to my circumstance. I agree to pay the full session rate if I give 2 hrs notice or less, or if I miss an appointment without giving notice. I understand that payment is due at the time of service.  I do forever release Julia Donaldson, DBA Portland Prenatal Massage  from all liability of any nature whatsoever, whether past, present, or future for any injury or damage which may occur to myself or my family as a result of my receiving massage therapy and bodywork from this point forward. I agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal or administrative action that has arisen or may arise directly or indirectly out of my  participation in this therapy. I have completed this health form to the best of my knowledge.  By agreeing to and submitting this form, I agree to abide by the polices, terms and conditions set forth and I realize these policies may change at any time without notice. 
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