Pregnancy Release Form printable pdf download

Pregnancy Release Form

Intermezzo Massage

Denise Renee, CMT, RMT

Pregnancy Release Form

Client Information, Verification & Medical Release Form

Pregnancy is a time of major structural, physiological, psychological, and spiritual and social changes. Some of

the changes produce discomforts and concerns, which can be addressed with appropriate therapy and education.

Possible Benefits

Massage therapy during pregnancy is not intended to replace any appropriate pre-natal care from a qualified

medical doctor. When used as a form of adjunctive health care, some of the possible benefits include:

1. Reduction of stress and promotion of relaxation through emotional support and physical nurturance.

2. Increased blood and lymph circulation, reducing edema.

3. Facilitation of respiratory, gastrointestinal, hormonal, and other physiological processes.

4. Reduces musculoskeletal strain and pain, especially in the back, neck and shoulders.

5. Development of kinesthetic awareness necessary to actively participate in the labor process.

Contraindications for Pregnancy Massage

If complications are resolved, massage may be possible with a physician’s release.

1. Threatened miscarriage

2. Early labor

3. Placental dysfunctions

4. Hypersensitive disorders of pregnancy including pregnancy induced hypertension, (PIH),

1. GEPH (Preeclampsia)

5. Gestational diabetes

6. Intrauterine growth retardation

7. Severe varicose veins

8. Thrombophlebitis

9. Skin irritation and/or discharge

10. Fracture, bleeding, burns or other acute injury

11. Cancer or undiagnosed lumps

12. Infection of any kind

P.O. Box 57633 • Sherman Oaks, CA 91413 • Phone (818) 800-7247 • Fax (818) 784-5505

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Pregnancy Release Form