If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site


You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]


Pregnancy Massage Informed Consent Form

New form editor - use the controls on the left to alter or add to this form.

You are making a decision whether or not to receive a prenatal massage. Please review the following contraindications associated with this treatment. After reviewing the contraindications you may decide to cancel your prenatal massage. There will be no financial consequences associated with that action.

We have a Physician and Midwife Approval Form we can send to them if you need.

If you are less than 37 weeks along in your pregnancy and are experiencing any of the above symptoms, this could be a sign of premature labor. Please seek medical attention immediately.

If you are experiencing any of the above symptoms, this could be a sign of preclampsia. Please seek medical attention immediately.

I understand that massage therapy given here is for the purpose of stress reduction, relief from muscle tension or spasm, or for increasing circulation and energy flow. if at any time I feel discomfort, I will inform my massage therapist. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. As such, the massage therapist does not prescribe medical treatment of pharmaceuticals, nor do they perform any spinal manipulations. It has been made very clear to me that massage therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any ailments that I have. I understand and agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy, I HEREBY HOLD HARMLESS AND INDEMNIFY Prairielands Chiropractic Clinic, P.C., their principals, therapists, and agents from all claims and liability whatsoever. I have stated all my known medical conditions and will keep the massage therapist updated on my physical health. The massage given here is therapeutic. Any attempt to sexualize the relationship will not be tolerated, and is grounds for termination of the massage and I will be liable for payment of the scheduled appointment. Cancellations and/or rescheduling must be made NO LESS THAN FOUR (4) HOURS (medical emergencies excluded) prior to the session OR FULL PAYMENT IS EXPECTED AND WILL BE BILLED. If late, our session will still end at the appointed time.

Your signature indicates that you have read the information provided above and have decided to receive a prenatal massage.

Go to top of page