Health Care Provider's Release for Massage During Pregnancy

________________________ (Patient's name) is under my supervision for prenatal health care. She has requested therapeutic massage and bodywork at Spa Materna, LLC.

These services are provided as adjunctive health care by North Carolina licensed massage and bodywork therapists. When an individual has experienced complications in her pregnancy, it is our policy at Spa Materna, LLC to work with her only if her health care provider has reviewed this request. Please verify your clearance of this request by your signature below. Please list any precautions or limitations in massage procedures for this patient which you feel are appropriate. Thank you for your assistance.

Precautions/Limitations:___________________________________________________

_______________________________________________________________________

Signature of Health Care Provider_____________________________________

Date:____________________________________________________________

Spa Materna, LLC

(828) 254-2222

640 Merrimon Ave Suite 204
Asheville, NC 28804
spamaterna.com