Your Name (required)

    Your Email (required)

    Telephone (required)

    Your pregnancy (required)

    1st trimester months 1-3 or weeks 2-122nd trimester months 4,5,6 or weeks 14 - 28 (no supine or right side)3rd trimester months 7,8,9 or weeks 29 - 40. (Left side only)

    Your physician has stated massage is safe for you and your unborn
    child (required)

    Number of Weeks of pregnancy today? (required)

    Have you had complications during this pregnancy? (required)

    Do you have a history of miscarriage? (required)

    Have you been told this pregnancy is a high-risk pregnancy? (required)

    Based upon the information you provided a determination will be made by your massage therapist to either proceed with a massage session or postpone until another time. Only you and your physician can determine if massage is medically appropriate for you and your unborn child.

    Sign here:

    Date: