Pregnancy Release Form (Page 6 of 6) in pdf

Pregnancy Release Form Page 6

Intermezzo Massage

Denise Renee, CMT, RMT

Pregnancy Release Form

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

______________________________________ (patient),

has requested pre-natal therapeutic massage.

These services are provided as adjunctive healthcare. When an individual’s pregnancy is considered high risk, or

she has experienced complications or contraindications, it is my policy to work with her only if her maternity

healthcare provider has reviewed this request and given written permission for her to participate in massage

therapy. Please verify your clearance of this request by your signature below. Please also list any and all

precautions or limitations which you feel to be appropriate. Thank you for your assistance.

– Denise Renee C.M.T.

Precautions/Limitations:

__________________________________________________________________________________________

Physician Name ______________________________________

Phone: __________________________

Physician 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 6