I have read the above conditions and symptoms which may make massage therapy contraindicated. I have circled any of them that certain to me and/or past experiences with pregnancy. I have disclosed all of my high-risk factors. I have discussed with my prenatal healthcare provider/physician any health concerns that I had about receiving massage therapy. I agree that my healthcare provider/physician has given me clearance to receive massage therapy. I understand the information contained on this form and am aware that I will be receiving massage therapy as an adjunct form of healthcare only. This therapy is not meant to replace appropriate medical care. I release LaVida Massage of Canton and the massage therapist of any and all liability for any harm that may unintentionally occur.