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Prenatal Intake and Consent

Our Prenatal Intake and Consent form is required to be completed by any individual woman with a confirmed pregnancy or believed to be pregnant prior to receiving any prenatal massage services with MHH Massage. It is the responsibility of each individual to adhere to the consent and use of our services. Complete/submit the form below prior to your session with us.

PRENATAL INTAKE AND CONSENT

Complete/submit the required MHH Massage"Prenatal Intake & Consent" form prior to your massage session (if you are 12+ weeks or over).

First name*

Last name*

Email*

Phone*

Emergency Contact Name

Relationship To You

Emergency Contact Phone

What is your primary reason for appointment and the areas of pain?

Describe briefly (even if only therapeutic)*

Are you interested in focused attention to a specific area(s)?

Is there a specific area you'd like us to focus on?*

Yes

No

Describe the focus area(s) (if any)*

Are there any areas of the body you wish to avoid having massaged?

Multi choice*

Yes

No

Describe areas to avoid (if any)*

List all medications you are currently taking?

List all medications (if any)*

List all past or recent injuries, surgeries, or accidents?

List all with year (if any)*

List all conditions you've had medical treatment for in the past year?

List all conditions (if any)*

How did you hear about "My Healing Hands Massage"?

Please choose one*

Has any physician recommended massage during your pregnancy?

choose one*

Yes

No

Has your physician ever advised you against prenatal massage?

Choose one*

Yes

No

Is your pain due to a recent accident, sports injury, or other trauma?

Choose one*

Yes

No

What is your experience with receiving prenatal massage?

Select one*

1st massage ever

I've had massages

Are you confirmed pregnant or think you may be pregnant?

*

Yes

No

If confirmed pregnant, are you at least 12 weeks or more (required)?

*

Yes

No

Prenatal Waiver of Liability

I agree if confirmed pregnant that I'm at least 12 weeks or more and medically cleared, healthy and able to receive prenatal massage.

I release the massage therapist/practitioner and MHH Massage of all liability for any harm to me or my fetus(es), including miscarriage, pre-term labor, or any other complications that may unintentionally occur during or after my massage treatments.

Informed Consent Agreement

I acknowledge and agree that massage therapy is NOT a substitute for medical care and or any treatment and that it is recommended that I work with my primary caregiver for any condition(s) I may have including clearance to receive prenatal massage.

I acknowledge that I am free of COVID-19, seasonal flu, or other contagious conditions.

I acknowledge that I am at least 18 years of age and of sound mind at the time of consenting to prenatal massage.

I have read and agree to MHH Massage Terms, Conditions, and Privacy Policy viewable by clicking the link below: www.myhealinghandsmassage.com/terms-conditions

Sign Here*

Sign in the box or use the keyboard to type.

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MY HEALING HANDS MASSAGE

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Events and Booking Inquiries

832-303-9674 (text, voice, and call)

Booking Hours of Services

Monday - Saturday 9am to 10pm

Sunday's - Sorry We are Closed

By Appointment Only, No walk-ins*

Studio At - Private Residential

City/State - Houston, TX 77026

District - Kashmere Gardens (610 N loop)

Parking - Free in driveway for customers

Details - Provided to you by email

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