Prenatal Massage Intake Form - Victoria Pereira, LMT

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Emergency Contact Name *

Emergency Contact Phone *

Occupation *

Have you received a professional massage before *

Yes

No

If so, how long ago?

Are you currently taking medication? *

Yes

No

If yes, please list which medications

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Have you experienced any serious or chronic illnesses, injuries, or surgeries? *

Yes

No

If you answered "yes" to the above, please explain.

Prenatal Care Provider / Doctor *

Provider's Phone Number

May I contact? *

Yes

No

Due Date * +

How many weeks pregnant will you be as of your massage appointment date? *

Are you experiencing a high-risk pregnancy according to your doctor/prenatal care provider? *

Yes

No

If you answered "yes" to the above, please explain.

Please check any current issues you are experiencing during this or earlier pregnancies. *

Any other conditions or problems in current or past pregnancy? *

Yes

No

If yes:

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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