Pregnancy Release Form (Page 5 of 6) in pdf

Pregnancy Release Form Page 5

Intermezzo Massage

Denise Renee, CMT, RMT

Pregnancy Release Form

Maternity Healthcare Provider’s Release for Therapeutic Massage During a Normal Pregnancy

______________________________________ (patient), is under my supervision for pre-natal healthcare. Her

pregnancy is progressing normally.

Therapeutic massage would, in my opinion, be an acceptable form of

adjunctive care during her pregnancy. This patient has no contraindications or high risk pregnancy factors that

would prohibit her from participating in bodywork and massage therapy. I have listed below any limitations in

massage procedures for this patient:

__________________________________________________________________________________________

Physician Name ______________________________________

Phone: __________________________

Physician Signature: __________________________________

Date: ___________________________

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

• DR@ • Page 5 of 6

Pregnancy Release Form Page 5