Street Address Line 2
State / Province
Postal / Zip Code
What is your birthdate and age?
What date did you deliver?
What number pregnancy/ baby is this?
Did you have a C-Section or vaginal delivery?
Are you experiencing incontinence or have you been diagnosed with a prolapse?
Are you still bleeding?
Are you nursing?
Where are you feeling pain?
What do you hope to accomplish with this massage?
Have you had massage before? If yes, what types of massage?
Is there anything else I might need to know?
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