Save time- complete your new client intake forms ahead of time.

PREGNANCY Massage Release form

Please fill out the following form prior to your first PREGNANCY MASSAGE with Serendipity Wellness Studio. If it is also your first massage with us, please complete the MASSAGE INTAKE FORM as well

Appointment date

First Name

Last Name

During pregnancy, the body undergoes major changes of both a physical and psychological nature. Massage therapy can be safe, drug free method to release muscle tension and emotional stress. I understand that a massage therapist is not a medical doctor and that massage therapy does not replace routine obstetrical care.

I have reviewed the following list of pregnancy complications, and verify that I do not currently have any of the following conditions or symptoms:

A diagnosis as a high-risk pregnancy by my physician

Pre-term labor/possible miscarriage: discharge of blood, amniotic bag ruptured, pains or contraction in the uterus

Pre-eclampsia (GEPH): unusual weight gain, protein in urine, high blood pressure

Eclampsia (toxemia): severe water retention, headaches, back pain, vomiting, visual disturbances

Gestational Diabetes: abnormal appetite/thirst. sugar in urine

Deep Vein Thrombosis: pain, redness, or swelling isolated to one leg

I have discussed this with my physician or other prenatal health care practitioner. I affirm that I do not currently have any of the above conditions except as listed here: (list any symptoms from above list or other conditions relevant to receiving massage, or write none.)

If I suspect that I develop any of the above symptoms, I will promptly notify the massage therapist in writing, and I will obtain a written release from my obstetrician before seeking additional massage. I consent to allowing my massage practitioner to contact my primary care provider regarding my condition.

I understand that if I have any of the above conditions that I must have written consent from my physician prior to receiving massage

I permanently release Serendipity Wellness Studio, all therapists either employees or independent contractors, and their insurers, heirs or assigns, from all liability to me or my unborn child that may arise as a result of my receiving massage therapy during this pregnancy. I agree to defend and hold harmless Serendipity Wellness Studio, and all therapists, from any claims that may arise as a result of my receiving prenatal massage

Obstetrician’s name and phone number:

Due Date

Signature

Thanks for submitting! We are looking forward to seeing you!