Phone# (682)463-9143
945 Sgt. Ed Holcomb Blvd
Conroe, Texas, 77304
ME#4554
Cynthia Scott,BCTMB,LMT,MTI,CLT,COMT,CPMT
Birgit Holback, RN, LMT
Sydney Knight, LMT
Chad Dickson, LMT
Emma Scott, RYT 200 Yoga
Consent Forms
Massage for the Entire Family. In-Home Healthcare and Group Classes.
Parent & Child Massage Class Registration Form
Parent & Child Massage Class Registration Form
Class Dates:
Class Location:
Class Time:
Cost:
Payment method:
Child’s Name:_______________________________________ Birthdate:_____________________
Caregiver’s Name(s) : ______________________________________________________________
Address:_________________________________________________________________________
City:_________________________________________________State:___________Zip:_________
Phone:________________________ Cell/Pgr:________________________
Email: ___________________________________________________________
Referred By:_______________________________________________________
Why are you interested in learning infant massage?
____________________________________________________________________________________________________
Is there any relevant information about the pregnancy, child birth, about you or the child, that I should know?
____________________________________________________________________________________________________
Do not attend class if:
You or your child is not feeling well
Your child has a temperature (fever)
Your child has had recent immunizations (within 48 – 72 hours prior to class)
If you have any questions prior to class, please feel free to contact me via my contact information below.
All my best!
Cynthia "Cindy" Scott LMT/Tx #122542, BCTMB, CLT, CPMT, COMT
MTCINDY-143 (682)463-9143
Parent & Child Massage Class Lessons | Consent Form
Massage therapy for an infant/child is not intended to replace other forms of healthcare. Used as a form of adjunctive healthcare, potential benefits for the child include:
Skeletal:
- Aids in supporting good posture and balance
- Reduces muscle tension that could lead to potential medical problems
- Increases nutrient flow to bones
Muscular:
- Relieves muscle tension and spasm
- Aids in removal of lactic acid & carbonic acid which build up after strenuous activity
- Increases the flow of blood and nutrients to muscles
- Can increase or decrease muscle tone depending upon amount of pressure
- Can reduce or increase joint mobility depending upon amount of pressure
Digestive:
- May relieve constipation
- May relieve gas
- Reduces water retention
Cleans the blood by toning the kidneys
Circulatory:
- Stimulates blood and lymph circulation
- Helps strengthen the immune system
- Releases toxins held in the body
Respiratory:
- Improves breathing patterns
- Helps reduce respiratory problems
- Relieves tension in the chest allowing the lungs to expand more fully
Nervous:
- Relaxes and calms baby
- Helps baby to sleep
- Raises endorphin levels, promoting healing
- Provides a safe and easy release from frustration and hyperactive behavior
- The Vagus Nerve is stimulated influencing food absorption hormones (Insulin & Glycogen)
Child’s Name:_____________________________________ Birthdate:_____________________
Caregiver’s Name : ______________________________________________________________ Address:_______________________________________________________________________
City:________________________________________________State:___________Zip:_______
Phone:_______________________ Cell/Pgr:____________________
Email: ___________________________________________________________
Referred By:_______________________________________________________
In case of emergency.
Name: _____________________________________ Phone:________________
My healthcare provider is:
________________________________________________ Phone:________________
Infant/Child Massage is contraindicated if the child:
Has High Fever/Temperature
Has an acute infection, staph infection, illness or disease
Has a skin disorder which may be contagious or cause inflammation
Has open sores or lesions
Has had recent immunization/vaccination (wait 48 – 72 hours)
Has any life threatening medical condition
Has an unhealed umbilical cord (tummy massage contraindicated)
Has swollen lymph nodes
Has blood clots or a blood condition
Has diarrhea or other sickness
Common Precautions for Infant Massage include:
Apnea
Bradycardia
Tachycardia
Abdominal Distention
Gastrointestinal or Jejunostomy feeding tubes
Hydrocephalus
Inflammations
Edema
Dysplasia
Hemophilia
Jaundice
Recent Surgery
HIV/AIDS
Tumors
Cancer
Seizure Disorders
Please indicate any of the high risk factors, complications that I should be aware of:
Is there other relevant information about the pregnancy, child birth, about you or the child, that I should know?
Please list any health conditions or medication for infant/child:
_______________________________________________________________________________________________________
I, ______________________________, understand that I will be participating in infant massage therapy lessons as a form of adjunct health care.
I have noted above all complications, risks, or conditions my child has experienced AND I have obtained my child’s healthcare providers release.
I understand that I will be receiving infant massage therapy lessons as a form of adjunctive health care only and that it is not a substitute for other healthcare provided by a medical doctor or other licensed provider.
I hereby release and hold harmless and defend the practitioner (Infant Massage Teacher) from any claims, liability, demands and causes of action from my and my child’s participation in this therapy.
Signature:________________________ Date:________ Print Name:_____________________
Teacher’s Signature:__________________Date:________ Print Name:_____________________