Pregnancy 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:

How far along are you into your pregnancy?

How are you currently feeling in your pregnancy?

Do you have any conditions brought on by pregnancy or in general that you feel could effect the treatment?

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.

I understand that the massage I receive is for relaxation and support during pregnancy and is not a substitute for medical care.

Yes

I have informed my therapist of all known medical conditions, pregnancy complications, and medications I am currently taking.

Yes