Pregnancy Form

Relax & Be Well

Therapeutic Massage

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Contact
Essential Oils

About
Testimonials
Contact
Essential Oils

Name*

Address*

Phone*

Email Address*

Birthdate*

Emergency Contact Name & Number*

Referred By

Age*

Week of Pregnancy *

Due Date *

Are you a high risk pregnancy? *

YesNo

If yes, please have physician note authorizing therapeutic massage

Are you expecting*

One BabyMultiples

Please 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 APPLY

Waiver of Liability and Consent to have Massage*

I agree to submitting intake forms online and waive all claims.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.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.

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