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Intake Form _Pregnancy Massage

*This form is an example and does not constitute legal advice. You should consult with a legal professional to create a waiver that meets your specific needs.

First name*

Last name*

Email*

Phone

Birthday

Month

Day

Year

Date of Scheduled Appointment*

What is your occupation?*

What are your hobbies?

How many weeks of pregnancy are you? *

Is this your first pregnancy? *

Yes

Other

Are you carrying multiple babies? *

Yes

Other

Is your pregnancy considered "high-risk"? *

Yes

Other

By checking this box, I understand if my pregnancy is considered "High-Risk", a physician's or midwife's note of clearance is REQUIRED for massage. This is to ensure the safety of you and your baby. Please have the doctor's note available before the schedule appointment.

How many professional massages have you had within your lifetime? *

If you have had a professional massage in the past, have you ever had a professional massage while pregnant?*

Yes

Are you currently allergic to any of the following?

Nut-based oils (like almond oil)

Scents/fragrances

Lotions

Other

Are you experiencing any of the following? (check all that apply)*

Swelling (edema) in hands or/and feet

Low back or hip pain

Sciatica

High blood pressure (pregnancy-induced)

Gestational Diabetes

History of pre-eclampsia

Other

What are your treatment goal(s)?*

Relaxation

Pain Relief

Stress Relief

Better Sleep

Other

Any "off-limits" zone due to injury or personal preference?*

What is your current most discomfortable area/location on your body , and o n a scale of 1-10 , least to greatest, what is your current discomfort level in that area*

Please list any additional medical conditions & preferences that were not covered in the assessment.

By checking this box, I understand that massage therapy during pregnancy is a specialized service, I have consulted my OB/GYN or midwife and have been cleared for massage. I undertand that I must inform the massage therapsit of any changes in my pregancy or physical condition immediately. I acknowledge that I can stop the session at any time if I feel uncomfortable.

By checking this box I confirm that I do NOT have any of the following conditions which are contraindicate for massage:

Fever/Acute Illness: Massaged circulation can worsen symptoms/spread infection.
Contagious Disease: Skin infections (ringworm, impetigo) or systemic viruses (flu, COVID-19)
Recent Blood Clots (DVT): Massage can dislodge a clot, leading to embolism.
Uncontrolled Hypertension: high blood pressure that isn't managed by medication
Heart conditions: increase venous return

By checking this box, I confirm that I will disclose any of the following to my Massage Therapist before massage so areas can be avoided if need be to the following:

Inflammation/Injuries: recent fractures, severe sprains, or acute swelling (wait 48-72 hours)
Skin Issues: Open wounds, burns rashes, or severe varicose veins.
Medical Implants: recent surgical sites, pacemakers, or artificial joints (work around them)

By checking this box, I willl provide to the Licenses Massage Therapist a healthcare provider signed "approval for massage" note if I have the following conditions:

Cancer: massage is often beneficial, but pressure and technique must be modified for patients in active treatment.
Pregnancy: Usually safe, but requires a trained therapist and specific positioning (side-lying) after first trimester.
Blood Thinners: Clients on medications like Warfarin or Eliquis may bruise very easily.

By checking this box, I confirm that the personal and medical information provided in this intake form is accurate to the best of my knowledge.

By checking this box, I agree to inform the massage therapist of any changes in my health or medication BEFORE my schedule session starts.

By checking this box, I understand that massage therapist is intended to enhance relaxation, reduce pain and improve soft tissue function. I understand that massage therapy is not a substitute for medial examination, diagnosis, or treatment. I understand I should consult a physician for any physical or mental aliment I am aware of.

By checking this box, I acknowledge that while massage is generally safe, there are some risks, including temporary muscle soreness, bruising, or lightheadedness. I understand that the massage therapist will use the information I provide to minimize these risks.

By checking this box, I understand that professional clinical draping will be used at all times to ensure my privacy and warmth. Only the area being worked on will be undraped within the comfortability of the client.

By checking this box, I understand that all personal, medical, and health related information shared with Revival of Hope Wellness is strictly confidential. Your "Protected Health Information" (PHI) includes your medical history, treatment notes, and contact details. My information will not be shared with, sold to, or discussed with any third consent unless legal circumstances by law is enforced.

By checking this box, I agree to the Revival of Hope Wellness cancellation policy I understand that missing appointments without a 48 hour notice may be subject to a cancellation fee.

By checking this box, I understand that by receiving services in my home/office, I am responsible for providing a safe and clear environment for the massage therapist to work. I am also responsible for providing a bathroom that has hot water for the massage therapist to properly prepare for the service including washing of hands. I release Revival of Hope Wellness from any liability related to the workspace provided.

By checking this box, I understand that any illicit or suggestive remarks or advances made by the client will result in the immediate termination of the session, and I will be liable for full payment.

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Signature*

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Intake Form _Pregnancy Massage

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