Contraindications for Pediatric Massage include:

• Fever
• Acute infection, staph infection, illness, or disease
• Skin disorder/condition which may be contagious or cause inflammation (fungus, rashes, herpes)
• Open sores, wounds, or lesions
• Recent immunizations/vaccinations (wait 48-72 hours)
• Life-threatening medical condition
• Unhealed umbilical cord (tummy massage contraindicated)
• Swollen lymph nodes
• Blood clots or blood condition
• Diarrhea or other sickness
• Inflammation
• High blood pressure
• Hernia
• Osteoporosis
• Varicose veins
• Broken bones
• Deep vein thrombosis
• Pain

Common Precautions for Pediatric Massage may include:

• Apnea
• Bradycardia
• Tachycardia
• Abdominal distention
• Gastrointestinal or Jejunostomy feeding tubes
• Hydrocephalus
• Inflammations
• Edema
• Dysplasia
• Hemophilia
• Jaundice
• Recent surgery
• HIV/AIDS
• Tumors
• Seizure disorders
• Agitation
• Impulsivity

As my child's parent/guardian, I understand that my child will be participating in pediatric massage therapy as a form of adjunct healthcare.

I have noted above all the complications, risks or conditions my child has experienced.

I understand in order for my child to receive pediatric massage therapy, he/she must give permission to the practitioner.

I understand that my child will receive pediatric massage therapy as a form of adjunctive healthcare only and that it is not a substitute for other healthcare provided by a medical doctor
or other licensed providers.

I hereby, release and hold harmless and defend the practitioner from any claims, liability, demands and causes of action from my and my child’s participation in this therapy.

Practitioner’s Contact Information:
Deandra E. Marionva NCLMBT#09987, CPMTII, CIMT
Three Little Bears Pediatric & Family Massage
336-681-4680
deandra@threelittlebearsmassage.com