Pregnancy Consent Form

Prenatal Massage Intake Form

Patient Name*

Date of Birth*

Email Address*

Street Address

Street Address Line 2

City

Province

Postal code

Country

Phone*

Emergency Contact

Full Name of the OB / Gynecologist / Midwife Handling Your Care:

Weeks of Pregnancy:

Due Date:

Have you experienced swelling? (Yes / No / Sometimes):

Have you experienced any changes in your veins? (Yes / No / Sometimes):

Have you experienced any complications / medical issues?

Have you been pregnant before?

Yes

What type(s) of birth(s) did you have? (cesarean / vaginal / hospital / home / birthing center):

Do you intend to attempt a vaginal delivery after having previously had a c-section (V-BAC)? (Yes / No / NA):

Reason for today's visit and current areas of discomfort:

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Current Date*