Prenatal Massage Intake Form

I, ________________________ have received and read the attached written

information about the possible contraindications to massage therapy during

pregnancy. I understand and confirm that:

• I have not experienced any of the complications listed on the attached

sheet;

• I have not experienced any of the conditions listed, which would make it

unwise to have massage therapy;

• I am experiencing a low-risk pregnancy;

• I am receiving medical care including regular check-ups throughout my

pregnancy.

My physician and I have defined the following exclusions to the above

statements:

________________________________________________________________

______________________________________________

Signed: _____________________________ Date: ______________

I understand that I will be receiving massage therapy as a form of adjunctive

health care only and that this therapy is not intended to replace appropriate

medical care.

Having been fully advised of the risks, contraindications, and complications to

massage therapy during pregnancy, I have decided to participate in the therapy.

Accordingly, I do forever release the practitioners and their insurers, and their

respective officers, directors, stockholders, successors, employees, and agents

from all liability of any nature whatsoever, whether past, present, or future, for

injury or damage which may occur to myself or my family as a result of my

receiving massage therapy during this childbearing year.

I further 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 from my and my child’s participation in this therapy.

Signed: _____________________________ Date: ______________

Print name: __________________________