Have you received a professional massage before *
Are you currently taking medication? *
If yes, please list which medications
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Have you experienced any serious or chronic illnesses, injuries, or surgeries? *
May I contact? *
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Are you experiencing a high-risk pregnancy according to your doctor/prenatal care provider? *
Please check any current issues you are experiencing during this or earlier pregnancies. *
Any other conditions or problems in current or past pregnancy? *
I have completed this intake form to the best of my knowledge. If I am currently having or develop complications with my pregnancy, I will discuss the complications with my massage therapist and will have a medical release for massage signed by my prenatal care provider before continuing bodywork. I understand that my massage therapist is not a doctor and cannot diagnose conditions. I understand that massage is a health aid and does not take the place of a physician's care. Any information exchanged during a bodywork session is confidential and is only used to provide you with the best massage and bodywork services. If I am unable to make a scheduled appointment, I agree to cancel the appointment at least 4 hours in advance. If I do not give four hours advance notice, I agree to pay any missed appointment charge. I understand that I am responsible to pay for my massage session in full at the end of the session. Please type your name below to agree with the above statements. *
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