Pregnancy Consent Form Prenatal Massage Intake Form Client Information: Name*Birthday*Email address*Street AddressStreet Address Line 2City ProvincePostal codeCountryPlease selectcanadaPhone*Emergency Contact Pregnancy & Health Information OB/Gyn/Midwife handling your care:Weeks of Pregnancy: Due Date:Swelling (Yes/No/Sometimes):Changes in veins?Complications/Medical Issues?Pregnant before?YesNoIf Yes, Types of births (cesarean / vaginal / hospital / home / birthing center):Attempting V-BAC?Current ConcernsReason for today's visit and current areas of discomfort:Consent for Treatment with Therapeutic and Relaxation Massage ClinicSelect a date clean Save Signature Please click the save signature button before submitting. SendThis field should be left blank
