945 Sgt. Ed Holcomb Blvd
Conroe, Texas, 77304
Birgit Holback, RN, LMT
Sydney Knight, LMT
Chad Dickson, LMT
Emma Scott, RYT 200 Yoga
PreNatal Partner or Caregiver's Massage Class Form
PreNatal Partner OR Caregiver's Massage Class Registration Form
(FOR PRENATAL)Mother's Name:_______________________________________ Birthdate:_____________________
Caregiver’s Name(s) : ______________________________________________________________
Why are you interested in learning massage?
Is there any relevant information that I should know?
Do not attend class if:
You are not feeling well
If you/partner have a temperature (fever)
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
Common Precautions for Massage include:
Gastrointestinal or Jejunostomy feeding tubes
Please indicate any of the high risk factors, complications that I should be aware of:
I, ______________________________, understand that I will be participating in massage therapy lessons as a form of adjunct health care.
I have noted above all complications, risks, or conditions that I experienced AND I have obtained healthcare providers release.
I understand that I will be receiving 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 (Teacher) from any claims, liability, demands and causes of action from my/our participation in this therapy.
Signature:________________________ Date:________ Print Name:_____________________
Teacher’s Signature:__________________Date:________ Print Name:_____________________