Clone of Massage Therapy Client Intake Form

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Congratulations on your little one! Pregnancy is such a special journey, and I’m honored to be part of your self-care along the way. This form will help me understand your needs and ensure your comfort and safety during your prenatal massage.🤍

Full Name

First Name Last Name

Birth Date

MonthDayYear

Zip Code

Street Address

Street Address Line 2 (apartment number, unit number)

Zip Code

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Format: (000) 000-0000.

Occupation (optional)

1. How many weeks pregnant are you?

2. What is your estimated due date?

Date

3. Is your pregnancy considered high-risk by your healthcare provider?

4. Has your healthcare provider cleared you to receive prenatal massage?

Please know, Prenatal massage is offered only after the first trimester (12 weeks of pregnancy) and requires clearance from your healthcare provider before your appointment. Thank you!

5. Has your healthcare provider given you any restrictions or special instructions regarding massage, exercise, or physical activity?

If yes, please describe.

1. Do you currently have, or have you been diagnosed with, any of the following conditions or pregnancy complications? Select all that apply.

2. Do you have any other medical conditions or pregnancy complications that I should be aware of to help ensure your safety during your prenatal massage?

If yes, please explain.

3. Have you had any surgeries or medical procedures in the past?

If yes, please describe the procedure and approximate date.

4. Do you have any allergies or sensitivities to medications, latex, oils, lotions, fragrances and other relevant sensitivities. If you do not have any allergies or sensitivities please write "None".

5. Please list any supplements or medications you currently take, including prescription medications and over-the-counter medications. If you are not taking any, please write “None.”

6. Are you currently experiencing any of the following? Select all that apply.

7. Are you experiencing any new, unusual, or worsening symptoms during your pregnancy?

If yes, please describe.

Please ensure your healthcare provider is aware of any new, unusual, or worsening symptoms. If you have not discussed these symptoms with your provider, please do so before your appointment and obtain clearance to receive prenatal massage.

8. Have you experienced any recent vaginal bleeding, fluid leakage, painful contractions, severe headache, vision changes, or sudden swelling?

If yes, please explain.

Please ensure your healthcare provider is aware. If you have not discussed these symptoms with your provider, please do so before your appointment and obtain clearance to receive prenatal massage.

1. What would you like to focus on during your massage? Select all that apply.

2. Are there any areas you would like me to avoid?

3. What kind of pressure do you prefer?

4. Do you have any concerns about positioning or lying comfortably during your session?

5. Is there anything else about your pregnancy, health, or comfort that you would like me to know before your appointment?

Prenatal Massage Policies, Informed Consent & Client Agreement

Memoirs of the Body

Massage Policies

Confidentiality

Your personal and health information is confidential and will not be shared without your written consent, except as permitted or required by law.

Cell Phones

Please silence or turn off your cell phone during your appointment to help maintain a calm and relaxing environment.

Arrival and Tardiness

Please arrive on time for your appointment. If you arrive more than 10 minutes late, we may need to reschedule your session, depending on availability. The full length of your service cannot be guaranteed if you arrive late.

Cancellations and Rescheduling

A minimum of 24 hours' notice is required to cancel or reschedule an appointment to avoid losing your deposit. If you reschedule, your deposit may be transferred once to one future appointment.

Draping and Privacy

You may undress to the level that feels comfortable for you. You will have privacy to undress and will be properly draped throughout the massage. Only the area being worked on will be uncovered as necessary. Your comfort, dignity, and privacy will be respected at all times.

Consultation and Preparation

Before your session, your massage therapist will discuss your needs, preferences, comfort, and any concerns relevant to your pregnancy. Your massage may be adjusted based on your health information, stage of pregnancy, comfort, and provider recommendations.

Right to End a Session

You or your massage therapist may end the session at any time and for any reason.

Professional Boundaries

Inappropriate, abusive, or sexual behavior will not be tolerated. Such behavior will result in immediate termination of the session and may be reported to the appropriate authorities.

Prenatal Massage Informed Consent

Pregnancy Eligibility and Healthcare Provider Clearance

Prenatal massage is offered only after the first trimester, beginning at 12 weeks of pregnancy. Clearance from your healthcare provider is required before your appointment.

You are responsible for informing your massage therapist of any pregnancy complications, medical conditions, restrictions, or changes in your health. Healthcare-provider clearance does not guarantee that massage will be appropriate in every circumstance. Your massage therapist may request additional information, modify the session, postpone treatment, or decline the session when necessary for safety.

Medical Care and Scope of Practice

Prenatal massage is a complementary wellness service and is not a substitute for prenatal care, medical examination, diagnosis, or treatment. Massage therapists do not diagnose medical conditions, prescribe medications, or replace the advice of your healthcare provider.

You agree to continue routine prenatal care and follow your healthcare provider's recommendations throughout your pregnancy.

Pregnancy-Related Health Information

You agree to provide accurate and complete information about your pregnancy, medical history, medications, supplements, allergies, previous surgeries, and any relevant symptoms or complications.

You agree to inform your massage therapist of any new, unusual, or worsening symptoms, changes in your pregnancy, or new medical instructions before your session.

If you experience symptoms such as vaginal bleeding, fluid leakage, painful contractions, a severe or persistent headache, vision changes, or sudden swelling, you should contact your healthcare provider promptly and not proceed with massage until appropriately evaluated and cleared. Seek urgent medical care when symptoms may indicate an emergency.

Positioning and Comfort

Your comfort and safety are priorities throughout the session. Positioning may include side-lying or a supported, semi-reclined position, depending on your stage of pregnancy, comfort, and individual needs.

Pillows and other supports may be used to help maintain a comfortable position. You agree to communicate if you experience discomfort, difficulty breathing, dizziness, nausea, pain, or any other unusual sensation. The session will be adjusted or stopped as needed.

Pressure and Techniques

Prenatal massage techniques and pressure will be adapted to your pregnancy, comfort, health history, and any healthcare-provider restrictions. Pressure will remain within appropriate limits for prenatal massage and your individual needs.

Deep or aggressive techniques will not be used when inappropriate for pregnancy or your individual circumstances. Your massage therapist may avoid or modify work on certain areas when indicated by your health information, symptoms, or safety considerations.

You may request a change in pressure, technique, position, or focus at any time.

Possible Risks and Side Effects

Massage may cause temporary muscle soreness, tenderness, increased sensitivity, or mild discomfort. Although prenatal massage may help some clients manage muscle tension and general discomfort, results vary and specific outcomes are not guaranteed.

Pregnancy involves changing physical and medical needs, and massage may not be appropriate for every condition or stage of pregnancy. There may be circumstances in which a session needs to be modified, postponed, or declined. You agree to communicate any discomfort or concerns immediately.

Medical Restrictions and Referrals

You agree to follow all restrictions or special instructions provided by your healthcare provider. If your healthcare provider recommends avoiding massage or limiting certain techniques or positions, those instructions must be communicated before your session.

If your symptoms or health history raise concerns beyond the scope of massage therapy, you may be asked to consult your healthcare provider before receiving or continuing massage.

Voluntary Consent and Right to Withdraw

Receiving prenatal massage is voluntary. You may ask questions, decline any technique, request adjustments, or withdraw your consent and end the session at any time without penalty for doing so.

Your massage therapist may also stop or decline treatment if continuing would be inappropriate or raise safety concerns.

Client Acknowledgment and Consent

●By signing electronically, I acknowledge and agree that:

● I have read and understood these Prenatal Massage Policies and Informed Consent.

● I understand that prenatal massage is offered only from 12 weeks of pregnancy onward and requires healthcare-provider clearance before my appointment.

● I have provided accurate and complete information about my pregnancy, health history, medications, allergies, and relevant symptoms to the best of my knowledge.

● I understand the potential benefits, limitations, and possible risks of prenatal massage.

● I understand that prenatal massage does not replace prenatal medical care or treatment.

● I agree to inform my massage therapist of any new symptoms, changes in my health, or healthcare-provider restrictions.

● I understand that I may request adjustments or stop the session at any time.

● I have had the opportunity to ask questions and have received answers to my satisfaction.

● I voluntarily consent to receive prenatal massage under the terms outlined in this agreement.

Date

Signature

Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.

Prenatal Massage Client Intake Form

Medical History

Massage Preference