Informed Consent For Prenatal Massage

Name *

First

Last

Date of Birth *

YYYY/MM/DD

Email *

Mobile number *

Please include your country code if not in the UK e.g. 0081

Address *

Insurance details (if using insurance)

Please provide 1) the name of your insurer, 2) your membership no. and 3) how many session you've been approved for.

Emergency Contact *

(Name and Email/Mobile Number)

Do you have any of the following? (Please check if YES) *

Do you have any medical conditions not listed above that your therapist should be aware of? If yes, please elaborate.

Have you had any major surgeries to your abdominal and pelvic region? If yes, describe what was done and when.

Do you have a latex allergy? *

Do you have a nickle allergy? *

Are you currently on any medication, including any for your bladder/bowel? If YES, please list below.

If you are currently pregnant, please select the number of weeks you are. If you are not pregnant, please skip.

Selected Value: 4

Please select the number of weeks you are from 4 weeks to 42 weeks.

If you are currently pregnant, have you experienced/been diagnosed with any of the following? (Please check if YES).

If you have given birth within the past 1 year, please provide the date of delivery and what kind of delivery you had. If not, please skip.

e.g. YYYY/MM/DD, Vaginal delivery with epidural

Please briefly describe the problem that you're seeking treatment for? *

E.g. I leak urine when I jump and I have excruciating back pain getting out of bed in the mornings.

Where did you hear about Belly Strong? *

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