Prenatal Massage Medical Clearance Form
Client Information
Name
Date of Birth
Phone Number
Email
Estimated Due Date
OB/GYN or Primary Care Provider
Medical Information
Pregnancy Status (trimester, weeks, any complications)
Relevant Medical History
Medications
To be completed by health care provider
Provider Name
Provider Contact Information
Assessment / Comments
Medical Clearance for Prenatal Massage:
Approved
Approved with caution/special instructions
Not approved
If approved with caution, please provide instructions
Provider Signature
Date