Prenatal Massage

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Date

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Birth date

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Female

In case of emergency please call:

Have you experienced a therapeutic/pregnancy massage before?

Are any currently taking any medications? If so, what?

Are you experiencing areas of pain or discomfort? If yes, where?

Are you doing any form of exercise, such as yoga, walking or swimming?

Are you having any health issues we should discuss?

My pregnancy is progressing normally. Please state below how many weeks pregnant you are.

Some medical conditions could be contraindicated for massage. Please check if you have, had, or are currently experincing any of the following conditions:

I give Bella Salon & Spa permission to use photos taken of me for purpose of social marketing and/or advertising.

This form is a way for me to get to know you better and to service your needs. All information given both in writing and verbally will be kept in the strictest confidence.I understand that massage practitioners are not trained in the diagnosis and treatment of diseases. I confirm that I have consulted a medical doctor/midwife for all conditions checked and have received authorization to have a massage. by signing this release, I do hereby waive and release and the massage practitioner from all liability, past, present, and future.

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Prenatal Massage

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