Pregnancy Massage Consent & Health Check -

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Pregnancy Massage Consultation and Consent Form

The following information will be used to plan a safe and effective treatment.

Please answer the questions honestly and to the best of your knowledge. All information will remain private and confidential

Nameyour full name

Dateof appointment

How many weeks pregnant are you?

Has your pregnancy been determined to be ‘high risk’ by a health care professional

YesNo

Are you aware of or experiencing any symptoms or health conditions which would make massage unsafe for you or endanger the pregnancy?

YesNo

Have you read the information page on our website relating pregnancy massage, and understand the potential benefits, effects and risks?

YesNo

Have you been advised by a health care professional of any conditions or medical reason why you should not receive a massage during your pregnancy?

YesNo

By submitting this form, you consent to receiving massage therapy treatment after being advised of and understand the risks of massage therapy during pregnancy.