Consultation Form - Pregnancy Massage

Personal Information
Name
Name
Current Pregnancy
Current treatment
Please advise us if you have any particular requests or points which should be taken into account when conducting the massage
Do you suffer / are you suffering from any of the following:
Acute Infectious Disease
Varicose Veins
Injury
Jaw or Ear Pain
Fainting or Dizziness
Headaches or Migraines
Blood Pressure
Skin Conditions
Fungal Infections
Nervous Disorders
Phlebitis / Circulatory Problems
Whiplash
Rheumatoid Arthritis
Osteoarthritus
Kidney Disease
Diabetes
Asthma / Respiratory
Fibromyalgia
Crohn's Disease
Pelvic Inflammatory Disease
Epilepsy
Cancer
please read and confirm
You confirm your understanding that i) Cancellations within 24 hrs incur a 50% charge ii) Treatment is not a replacement for medical care iii) we do not diagnose medical illness or any other physical or medical conditions and iv) we do not prescribe medicines. *
You confirm you have stated all known conditions *
You agree to advise us of any updates to the above. *