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Prenatal Intake and Consent

Our Prenatal Intake and Consent form is required to be completed by any individual woman with a confirmed pregnancy or believed to be pregnant prior to receiving any prenatal massage services with MHH Massage. It is the responsibility of each individual to adhere to the consent and use of our services. Complete/submit the form below prior to your session with us. 

PRENATAL INTAKE AND CONSENT

Complete/submit the required MHH Massage"Prenatal Intake & Consent" form prior to your massage session (if you are 12+ weeks or over).

What is your primary reason for appointment and the areas of pain?

Are you interested in focused attention to a specific area(s)?


Is there a specific area you'd like us to focus on?

Are there any areas of the body you wish to avoid having massaged?

Multi choice

List all medications you are currently taking?

List all past or recent injuries, surgeries, or accidents?

List all conditions you've had medical treatment for in the past year?

How did you hear about "My Healing Hands Massage"?

Please choose one

Has any physician recommended massage during your pregnancy?

choose one

Has your physician ever advised you against prenatal massage?

Choose one

Is your pain due to a recent accident, sports injury, or other trauma?

Choose one

What is your experience with receiving prenatal massage?

Select one

Are you confirmed pregnant or think you may be pregnant?

If confirmed pregnant, are you at least 12 weeks or more (required)?

Prenatal Waiver of Liability

Informed Consent Agreement

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