Prenatal Massage Consent and Release Form

Prenatal massage, also known as pregnancy massage, is designed for pregnant women and offers numerous health benefits. It can relieve musculoskeletal pain, decrease muscle tension, ease leg cramps, reduce anxiety and depression, improve sleep quality, and enhance labor outcomes. This type of massage often combines techniques like Swedish and deep tissue massage, adapting to the needs and comfort of expectant mothers.

Please fill out the following form.

How far along are you in your pregnancy?

First trimester Weeks 1–13

Second trimester Weeks 14–27

Third trimester Weeks 28–40

Contraindications for Prenatal Massage

Prenatal massage has specific contraindications and precautions. Below is a partial list of common conditions that may contraindicate prenatal massage therapy. Please check all that apply to you during this pregnancy:

Please Read and Check Each Item Below

Information about prenatal massage, potential benefits, effects, risks, and possible alternative therapies have been explained to me and I understand this information.

My therapist has informed me of the contraindications of prenatal massage, and I have provided my therapist with an accurate and complete medical history to rule out any contraindications to receiving this treatment.

I have been given an opportunity to ask questions about prenatal massage and have had my questions answered to my satisfaction.

I have no contraindications for prenatal massage and am not currently experiencing any symptoms or complications listed above.

I am receiving regular medical checkups from my physician / healthcare provider.

I have spoken with my OB-GYN about receiving prenatal massage, and have received medical clearance to receive prenatal massage

I agree to communicate to my therapist any physical discomfort experienced during the session.

I release the massage therapist and business from all liability for any harm that may unintentionally result from this treatment.

I declare that the info I’ve provided is accurate and complete.

I further understand that massage is not a substitute for a medical examination or treatment and that I should see a physician or other qualified health specialist for any mental or physical ailment of which I am aware. I understand that massage therapists do not diagnose illness or disease, and nothing said during the treatment should be construed as such. My consent is informed and voluntary and I understand that I may withdraw my consent at any time except for actions already taken.

By signing this form I agree with the statements above and give my consent to proceed with prenatal massage.

Client Full Name

Today's Date

Your Due Date

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