Massage Liability Release Form

Name: _______________________________________________________

Address: _____________________________________________________

Phone: ___________________________   Date of Birth: _________________

Please mak all that apply:

High Blood Pressure	Headaches or Migraines	Arthritis, Bursitis or Gout	Varicose Veins
Cardiac or Circulatory Problems	Fibromyalgia	Carpal Tunnel Syndrome	Decreased Range of Motion
Auto-immune conditions	Abdominal Pain	Whiplash	Muscle Strains/Sprains
Cancer	Diverticulitis	Diabetes	Injury (past year)
Seizures	Herniated Disk	Scoliosis	Bruise easily

Do you have any allergies? _______________________________________________________

Are you seeing a healthcare professional? _________

Are you currently taking any medication, including aspirin and ibuprofen? _____________________________________________________________________________

Are you pregnant or trying to become pregnant? _________

Please indicate on the diagram below, areas in which you are feeling discomfort today.

^{Are there any areas that you would prefer I avoid today? _________________________________________________________}

Consent for Treatment

If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. Understanding all of this, I give my consent to receive care.

Client Name (printed) __________________________ Date ____________

Client Name (signature) ________________________ Date ____________

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Prenatal Release Form

Prenatal Massage Therapy Benefits - There are several observed or identified potential benefits to massage therapy during pregnancy, including:

• Relieves muscular tension, especially in the lower back, upper back, shoulders and neck
• Reduces stress on weight-bearing joints
• Enhances body awareness for better posture and less discomfort
• Assists with body mechanics and movement during structural change
• Supports birth process by relaxing muscles involved in labor and birth
• Eases anxiety and stress during time of transition
• Provides emotional support and nurturance

Prenatal Massage Therapy Contraindications – Performing massage therapy during pregnancy is contraindicated for women experiencing any of the following symptoms/signs:

• Bloody discharge
• Continual abdominal pains
• Sudden gush or leakage of amniotic fluid
• Sudden, rapid weight gain
• Increased blood pressure
• Protein or sugar in urine
• Severe back pain that does not subside with change in position
• Visual disturbances
• Severe nausea and/or vomiting (cannot keep anything down)
• Severe headaches
• Excessive hunger and thirst
• Increased urination in the second trimester
• Fever
• Diarrhea
• Excessive swelling in arms or legs
• Decrease in fetal movement over a 24-hour period
• Additional conditions – phlebitis, thrombosis, or suspected clotting conditions, any kidney, liver or spleen compromise or infection.  Local massage on areas with severe varicose veins and swelling are avoided due to clotting risk.

Prenatal High-Risk Pregnancies

It is a strict policy of Uniquely You to require a doctor’s release form in order to receive massage therapy during a High-Risk Pregnancy, which includes, but is not limited to:

• Early labor, miscarriage threat, placental or cervical dysfunction
• Gestational Edema Proteinuria Hypertension (GEPH)
• Preeclampsia
• Gestational Diabetes
• Pre-existing cardiac, renal, connective tissue or liver disorders/diseases
• Fetal genetic disorders
• Complications in previous pregnancies
• Three or more miscarriages

Prenatal Release Form

I, _______________________________________, have received and read the information written on the previous page about the benefits and possible contraindications of massage therapy during pregnancy.  I understand the information and confirm that:

• I have not experienced any the complications or conditions listed above;
• I am experiencing a Low-Risk Pregnancy;
• I am receiving medical care including regular check-ups throughout my pregnancy.

I understand that I will be receiving massage therapy as a form of adjunctive health care only, and that this therapy is not intended to replace appropriate medical care.

Having been fully advised of the risks, contraindications, and complications to massage therapy during pregnancy, I have decided to participate in the therapy.  Accordingly, I do forever release the practitioners and their insurers from all liability of any nature whatsoever, whether past, present, or future, for injury or damage which may occur to myself or my family as a result of my receiving massage therapy during this childbearing year. I further agree to hold harmless and defend the practitioner of and from all actions, claims, or other legal action that has arisen or may arise directly from my and my child’s participation in this therapy.

Pregnancy Due Date:________________________

Client Name (printed) __________________________ Date ____________

Client Name (signature) ______________________ Date:______________