Relax & Be WellTherapeutic Massage Toggle NavigationAboutTestimonialsContactHealth Intake FormPregnancy FormOncology FormPediatric Form (0-17)Essential OilsCOVID-19 (Coronavirus) Liability Release FormNew COVID-19 Massage ProtocolsAboutTestimonialsContactHealth Intake FormPregnancy FormOncology FormPediatric Form (0-17)Essential OilsCOVID-19 (Coronavirus) Liability Release FormNew COVID-19 Massage ProtocolsName*Address*Phone*Email Address*Birthdate*Emergency Contact Name & Number*OBGYN/Midwife Name, Clinic Name & Phone Number *Referred ByAge*Week of Pregnancy *Due Date *Are you a high risk pregnancy? *YesNoIf yes, please have physician note authorizing therapeutic massageAre you expecting*One BabyMultiplesPlease check any complications or conditions related to this pregnancy *anemiaback painblood clotsconstipationdiabetesedema/swellingfatigueheadachesheartburnhemorrhoidshigh blood pressureinsomnialeg crampslow blood pressurenauseaplacental dysfunctionpre-eclampsiapre-term laborsciatic nerve issuesseparation of pubic symphysisseparation of rectus muscles (in abdomen)skin disordersathlete's footplantar's wartsvaricose veinsNONE APPLYWaiver of Liability and Consent to have Massage*I agree to submitting intake forms online and waive all claims.I agree to hold harmless Relax & Be Well Therapeutic Massage, of all claims, including Andree Strauss, her spouse, her heirs, her property and associations.I understand that my information will not be shared with anyone outside of Relax & Be Well Therapeutic Massage without my written consent.I understand that I need a physicians approval for therapeutic massage if I am a high risk pregnancy.I understand that the massage therapist cannot diagnose any medical conditions, but they can recommend seeing a medical doctor or medical specialist with any concerns.I understand that if I choose to have a cupping session (alone or added to massage) that there may be visible marks left on my body, that may last up to a couple of weeks and that cupping is contraindicated on the abdomen, lower back and ankles during pregnancy.I have answered the above information to the best of my knowledge and will let the practitioner know if anything changes with my health history.Cancellation Policy*I understand that I will be charged 50% of my scheduled service fee if I cancel my appointment less than 24 hours before my scheduled time, with the exception of illness, emergency or inclement weather.I understand I will NOT be charged if I need to cancel within 24 hours due to COVID-19 symptoms in myself or another member of my household.This site uses Google reCAPTCHA technology to fight spam. Your use of reCAPTCHA is subject to Google's Privacy Policy and Terms of Service.SubmitThank you for submitting intake form. See you at your first appointment. If you need to schedule your first appointment Click the BOOK NOW BUTTON / PreviousNextPausePlayClose
