945 Sgt. Ed Holcomb Blvd
Conroe, Texas, 77304
Massage for the Entire Family. In-Home Healthcare and Group Classes.
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:_____________________