Pregnancy Massage Consultation Form

The following information is required for your safety, and to benefit your health. The following details will be treated in the strictest of confidence. It may however, be necessary for you to consult your G.P. or midwife before any treatment may be given.

Have you had any of these health problems during your pregnancy past or present?

According to my midwife/doctor I am a low risk/high risk pregnancy

May I have permission to contact your midwife if required?

Client Decleration

Client Decleration

Client Cancellation

4 + 13 =