Tranquil Massage & Wellness
PRENATAL MASSAGE THERAPY RELEASE
During pregnancy, the body undergoes major changes of both a physical and psychological nature. Massage therapy can be a safe, drug free method to release muscle tension and emotional stress. I understand that a massage therapist is not a medical doctor and that massage therapy does not replace routine obstetrical care. 
I have reviewed the following list of pregnancy complications, and verify that I do not currently have any of the following conditions or symptoms:
• A diagnosis as a high-risk pregnancy by my physician
• Pre-term labor/possible miscarriage: discharge of blood, amniotic bag ruptured,
pains or contraction in uterus
• Pre-eclampsia (GEPH): unusual weight gain, protein in urine, high blood pressure
• Eclampsia (toxemia): severe water retention, headaches, back pain, vomiting, visual
disturbances
• Gestational Diabetes: abnormal appetite/thirst, sugar in urine
• Deep Vein Thrombosis: pain, redness, or swelling isolated to one leg
I have had opportunity to ask the massage practitioner any questions I may have about pregnancy massage, and I have discussed this with my physician or other prenatal health care practitioner. I affirm that I do not currently have any of the above conditions except as listed here: (list any symptoms from above list or other conditions relevant to receiving massage, or write “none”) __________________________________________________________________________________________________________________________________________________________________________________________________
If I suspect that I develop any of the above symptoms, I will promptly notify the massage therapist in writing, and I will obtain a written release from my obstetrician before seeking further massage. I consent to allowing the massage practitioner to contact my primary care provider regarding my condition. 
By placing my signature on this form, I permanently release Wendy Raisley,LMT, and their insurers, heirs or assigns, from all liability to me or my unborn child that may arise as a result of my receiving massage therapy during this pregnancy. I agree to defend and hold harmless Wendy Raisley, LMT from any claims that may arise as a result of my receiving prenatal massage.
Signature: ________________________________________ Date: _______________
(Print Name)____________________________________ Due Date ______________
Obstetrician’s Name _____________________________________________________