Pregnancy Release Form (Page 4 of 6) in pdf

Intermezzo Massage

Denise Renee, CMT, RMT

Pregnancy Release Form

Client’s Verification, Release and Hold Harmless Agreement

I, ____________________________________ verify that I have received information concerning the possible

benefits and the contraindicated conditions for massage therapy during pregnancy. The massage practitioner,

Denise Renee from Intermezzo Massage, has been contacted by my pre-natal provider/physician regarding any

health concerns that I had about my participation in massage therapy.

Having read, discussed and understood the above information, I further verify that I have obtained my pre-natal

healthcare provider’s release due to any contraindications or high risk conditions of my pregnancy.

I understand that I will be receiving massage therapy as a form of adjunctive healthcare only and that this therapy

is not intended to replace any appropriate medical care.

I do forever release and hold harmless the practitioner and her insurers, and their respective officers, directors,

successors, employees and agents connected in any way to Intermezzo Massage from all liability of any nature

whatsoever, whether past, present or future for any injury or damage which may occur to myself, my baby or my

family as a result of my participation in this therapy.

I also agree to hold harmless and defend the practitioner from all actions, claims or other legal or administrative

action that arises or may arise out of my and my child’s participation in massage therapy.

Client Name: ________________________________________

Client Signature: _____________________________________

Date: ___________________________

Witness Name _______________________________________

Phone: __________________________

Witness Signature: ___________________________________

Date: ___________________________

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

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Pregnancy Release Form Page 4