Massage Pregnant Intake Form

Name *

Phone # *

Cell Phone #

Street Address *

City *

State/Province *

ZIP / Postal Code *

Country

Date of Birth *

Emergency Contact Name *

Contact Phone # *

Email Address *(To receive Appointments Reminders and Special Offers)

Have You Ever Had A Massage *YESNO

If Yes, Which Type

Please indicate any areas you want FOCUSED

Please indicate any areas you want AVOIDED

Pregnancy History

General information about your pregnancy/health history is helpful in planning a massage session that is safe and effective.

What week/month are you in this pregnancy? *

What’s your due date? *

What number pregnancy is this for you? *

How many children do you currently have? *

If yes, children’s ages?

Briefly explain any history of miscarriage

Briefly explain any history of fertility issues

Other, or specify Swelling or Bruising locations

Please explain any checked conditions listed above and anything else you think your professional should be aware of: *

Please list any medications prescribed or you are currently taking you think your therapist should be aware of *

Disclaimer: I agree that I will not hold blvd spa and its employees liable for any injury or condition that arises from application of massage despite completion of this form. This form is intended as an assessment tool only and serves as a guide for the application of massage not for medical treatment or medical assessment. If I experience pain or discomfort during the session, I will immediately inform the therapist so that the pressure may be adjusted. I understand that Massage Therapists are not qualified to perform spinal or skeletal adjustments, diagnosis, prescribe or treat any physical illness, and that nothing in the course of the session given should be construed as such. Draping will be used during this session. Only the body area being worked on will be uncovered. Clients under the age of 18 can’t have a service without clearance of a doctor.

I have stated all conditions that I am aware of and this information I provided is true and accurate to the best of my knowledge. I agree to inform my massage therapists immediately of any change in the conditions stated above on every visit moving forward. This consent form will stay on file and be used for this service and all future massage sessions. I acknowledge that this information is confidential and intended for review by massage therapists; that a medical referral may be requested of me; and that blvd spa is not liable for the management of any condition. I also understand that any illicit or sexually suggestive remarks or advances made by myself will result in immediate termination of this session, and I will be liable for full payment of the appointment.

Client Signature (Parent/Guardian If Minor) *

Date *

Massage Pregnant Intake Form

PLEASE MARK ALL CURRENT AND PAST CONDITIONS *