Prenatal Massage Form

Pre-natal Massage Consent Form

Name

First Name

Last Name

Email Address

Phone

Have you had a prenatal massage before?

How far along will you be at time of appointment?

Have you been diagnosed with any of the following medical conditions: Pre-eclampisa, Deep Vein Thrombosis (DVT), or any placenta problems (Previa, Accreta, or Abruption)?

Massage is contraindicated for the above medical conditions. A doctor's approval is required prior to any massage services

I understand that lying prone (face down) is contraindicated past 8-12 weeks of pregnancy. Lavande guests who wish to lie prone past the first trimester may choose to lie on the patented bodyCushion up until the third trimester with doctor's approval. I understand it is my responsibility to inform my therapist immediately if any postion is uncomfortable or painful

By checking this box I understand a doctor's approval is required prior to using the bodyCushion bolster system: referral must state at which point side-lying will be required

Yes

Are you currently experiencing any of the following?

Morning Sickness

Heartburn

Lower Back Pain

Varicose Veins

Gestational Diabetes

Edema (Swelling)

By initialing below, I consent to pre-natal massage. I understand it is my responsiblity to inform Lavande of any medical or health changes. I understand that it is my responsibility to inform my therapist if I am ever uncomfortable throughout the massage and reserve the right to end the massage at any point.

Prenatal Massage Form

Pre-natal Massage Consent Form

— Lavande —