Consent Forms

PreNatal Partner OR Caregiver's Massage Class Registration Form

Class Dates:

Class Location:

Class Time:

Cost:

Payment method:

(FOR PRENATAL)Mother's Name:_______________________________________ Birthdate:_____________________

Caregiver’s Name(s) : ______________________________________________________________


Address:_________________________________________________________________________

City:_________________________________________________State:___________Zip:_________

Phone:________________________ Cell/Pgr:________________________

Email: ___________________________________________________________

Referred By:_______________________________________________________

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

[email protected]

www.cindysmassage.com

MTCINDY-143 (682)463-9143

818-209-1918

Common Precautions for Massage include:

Apnea

Bradycardia

Tachycardia

Abdominal Distention

Gastrointestinal or Jejunostomy feeding tubes

Hydrocephalus

Inflammations

Edema

DVT

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:

_________________________________________________________________________________________________________

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:_____________________