Pregnancy Release Form (Page 2 of 6) in pdf

Pregnancy Release Form Page 2

Intermezzo Massage

Denise Renee, CMT, RMT

Pregnancy Release Form

High Risk Pregnancies

Written release from the pre-natal healthcare provider required for any of the following:

1. Pre-pregnancy diabetes mellitus

2. Cardiac, pulmonary, renal or liver disorders

3. Chronic hypertension

4. Previous problem pregnancy

5. Multiple pregnancy

6. Mother’s age under 20 or over 35

7. Drug or hazardous materials exposure

8. Suspected Rh-negative mother or maternal genetic problems, including DES exposure and

9. Other uterine abnormalities.

10. Risk of fetal genetic disorders

11. Convulsive disorders

Criteria for Massage Therapy

1. Pregnancy massage and bodywork is beneficial throughout your entire pregnancy.

2. If you have or have had any of the listed complications, conditions or high risk factors listed above or any

others not listed above, discuss your condition with your pre-natal healthcare provider and your massage

practitioner.

3. You may be able to receive therapy with written approval from your physician or pre-natal healthcare

provider, included in the attached release form.

4. If you would like to receive massage therapy and bodywork, please read and sign the following

verification and release agreement.

5. Please have your healthcare provider read the information sheet and read and sign the release at the

bottom of the verification/release agreement form attached.

6. Submit the signed forms at your massage appointment. Alternately, your healthcare provider may fax the

signed release form to our office.

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

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Pregnancy Release Form Page 2