New Client - Pregnant


First Name:

Middle Initial

Last Name

Street Address



Zip Code

Cell Phone Number

Email Address

Date of Birth

How did you first hear about us?

    If Pregnant  -  Mother's Release: I am stating to all pregnancy massage therapists and to StressBusters, Inc. that: I understand that I will be participating in massage therapy sessions as a form of adjunctive healthcare.  My pregnancy has been progressing normally and without any complications.

What is Your Due Date?

Who is Your Doctor (Ob/Gyn)?  Also Specify Midwife if you have one.

Question here

If "Yes" please explain.

Signature: Please Type Your Full Name [your typed name is your signature]
Your Full Name:

Cancellation/No-Show Policy
This policy allows us to offer the best service to each and every client.  Treatments lasting one hour or less: a 24-hour cancellation notice is required.  Treatments lasting 1 to 2 hours: a 48-hour cancellation notice is required.  Treatments lasting more than 2 hours: a 72-hour cancellation notice is required.  The full treatment fee will be charged for cancellations received with less notice.  However, if we are able to fill the appointment you will not be charged.  If you do not show up for any scheduled appointment you will be charged the entire amount of the scheduled treatment.

Please enter the code exactly as you see above: