TPB New Patient Intake Form Name * First Name Last Name Service * Ultrasound IV Drip Massage How far along are you? * Due date * OB/GYN or Midwife name Any complications so far? * No Yes Notes Have you experienced or been diagnosed with any of the following? * High blood pressure Gestational diabetes Preeclampsia Anemia Allergies Other conditions Current medications or supplements: * Are you currently experiencing any of the following? * Nausea Dehydration Fatigue Headaches Immune support Cramping Contractions Ultrasounds Only Have you had an anatomy scan with your doctor yet? Yes No Do you prefer a quiet bonding session or guided explanation? Quiet time to bond Detailed explanation during the scan A mix of both IV Therapy Only Have you ever had an IV reaction or side effect before? Yes No Have you received IV therapy before? Yes No Massage Only Any areas you'd like us to focus on or avoid? Preferred pressure: Light Medium Firm Have you received prenatal massage before? Yes No Do you have any of the following conditions? Sciatica Edema Lower back pain Hip or pelvic discomfort Muscle tightness Sleep issues Anxiety or stress Notes * Consent & Agreement I acknowledge that the services provided are wellness-focused and not a substitute for medical care. I have disclosed all relevant information and agree to proceed at my own discretion. * Thank you!
