Postpartum Massage Treatment Form

Janma Pregnancy Massage Treatment

Pregnancy Massage consultation form - Please fill in all relevant areas and submit before your treatment. I look forward to seeing you.

First name

Last name

Date of birth

Day

Month

Year

Address

Phone

Date of visit

Day

Month

Year

Emergency contact (name and number)

The following information will be used to help plan a safe effective massage treatment. Please answer the questions to the best of your knowledge:

When did you give birth?

What type of birth did you have?

Vaginal

C - Section

If you had a c-section how is your recovery? Please let me know how your scar has healed, if you have had any infection, or any other relevant information.

Did you experience any complications during your labour and birth that could cause an issue with your massage treatment? Or that you would like me to be aware of?

Do you have any health conditions that you feel might cause an issue with your massage treatment?

Do you have any areas that you would specifically like me to work on?

Do you have any allergies or aversions to any oils or lotions? If yes please state which:

I like to provide a post-treatment drink. Do you have a preference:

Ayurvedic hot milky Chai (Caffeine free)

Ayurvedic vegan hot milky Chai (Caffeine free)

Fresh Ginger and lemon tea

Ayurvedic CCF Tea

If you have anything else that you would like me to know before coming for your treatment please state here. For example, what you would like to achieve from the treatment or if you have any other personal information that you feel might be relevant.