Pregnancy Release Form
There are several observed or identified potential benefits to massage therapy during pregnancy including:
• Relieves muscular tension, especially in the lower back, upper back, shoulders and neck
• Reduces stress on weight-bearing joints
• Enhances body awareness for better posture and less discomfort
• Assists with body mechanics and movement during structural change
• Supports birth process by relaxing muscles involved in labor an birth
• Eases anxiety and stress during time of transition
• Provides emotional support and nurturance
Prenatal Massage Therapy Contraindications
Performing massage therapy during pregnancy is contraindicated for women experiencing any of the following symptoms/signs:
• Bloody discharge
• Continual abdominal pains
• Sudden gush or leakage of amniotic fluid
• Sudden, rapid weight gain
• Increased blood pressure
• Protein or sugar in urine
• Severe back pain that does not subside with the change in position
• Visual disturbances
• Severe nausea and /or vomiting
• Severe headaches
• Excessive hunger and thirst
• Increased urination in the second trimester
• Excessive swelling in our arms or legs
• A decrease in fetal movement over a twenty-four hour period
Some additional conditions that contraindicate massage therapy are any phlebitis,
thrombosis, or suspected clotting conditions, any kidney, liver or spleen compromise or infection. Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.
Prenatal High Risk Pregnancies
It is a strict policy of diVINE SPA to require a signed doctor's release form in order for the client to receive massage therapy services if a client has a high risk pregnancy. High risk pregnancies include, but are not limited to:
1.) Early labor, miscarriage threat, placental or cervical dysfunction;
2.) Gestational Edema Proteinuria Hypertension (GEPH);
4.) Gestational Diabetes;
5.) Pre-existing cardiac, renal, connective tissues or liver disorders/diseases;
6.) Fetal genetic disorders;
7.) Complications in previous pregnancies;
8.) Three or more miscarriages
I have received and read the written information about the benefits and possible contraindications of massage therapy during pregnancy. I understand the information and confirm that:
• I have not experienced any of the complications listed on the sheet below;
• I have not experienced any of the conditions listed, which would make it unwise to have
• I am experiencing a low-risk pregnancy;
• I am receiving medical care including regular check-ups throughout my pregnancy.
I understand that I will be receiving massage therapy as a form of adjunctive health care only and that this therapy is not intended to replace appropriate medical care.
Having been fully advised of the risks, contraindications, and complications to massage therapy during pregnancy, I have decided to participate in the therapy. Accordingly, I do forever release the practitioners and their insurers, and their respective officers, directors, stockholders, successors, employees and agents from all liability of any nature whatsoever, whether past, present, or future for injury or damage which may occur to myself or my family as a result of my receiving massage therapy during this childbearing year.
I further agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal or administrative action that has arisen or may arise directly from my and my child's participation in this therapy.
Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, massage/bodywork may be contraindicated. A referral from your primary care provider may be required prior to service being provided.
If you answer "yes" to any of the following questions, please explain as clearly as possible
I have read and understood this Client Intake and Health History form in its entirety. If at any time there are changes in the information given, or in my condition, I will notify the therapist and update this form before receiving additional massage. I have stated all my known medical conditions and have answered all questions honestly. If there is any information not directly requested on this form, which would compromise my ability to safely receive massage, I am responsible for bringing that information to the therapist's attention.
The massage treatment I am requesting is for the purpose(s) of relaxation, stress reduction, relief from muscle tension or spasm, to improve range of motion, circulation, or energy.
I understand the massage therapist does not diagnose or prescribe for medical illness, disease, or other disorders and that spinal manipulation is not part of massage therapy. I further understand that massage therapy is not a substitute for medical examination or diagnosis, and that I take responsibility for consulting with my physician for any ailment or condition of concern to me. If I experience any pain or discomfort during the massage session, I will immediately communicate that to the therapist so that treatment can be adjusted accordingly.
I understand that my feedback is an essential element in my treatment. If at any time I become uncomfortable during the massage, I may bring that to the therapist's attention and request that the session be modified, temporarily suspended, or brought to an end. However, I can ask that a session be discontinued at any time, for any reason, and the therapist will honor that request.
Unless in emergency or inclement weather, I acknowledge that if I am unable to keep a schedule appointment, 24 hours notice is required or I will be charged for the time reserved.
I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment.