I have read the aforementioned conditions and symptoms which make massage therapy during pregnancy contraindicated. The massage therapist/practitioner has discussed this information with me and provided opportunity for any questions. I have disclosed any and all high risk factors of my pregnancy.
I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy. I agree that my healthcare provider/physician has given me clearance to receive massage therapy.
I understand the information contained on this form and confirm that (1) I am receiving medical care including regular check-ups with a licensed healthcare provider. (2) I have not experienced any of the listed symptoms, conditions, or complications. (3) I am not currently experiencing any of the listed symptoms, conditions, or complications. (4) I am experiencing a low-risk pregnancy.
I understand that I will be receiving massage therapy as an adjunct form of healthcare only and that this therapy is not meant to replace appropriate medical care. I release the massage therapist/practitioner of any and all liability for any harm that may unintentionally occur during my treatment(s).