Pediatric Intake Form

Bonnie Be Bodywork, LLC

MNRI and Massage Therapy


(970) 462-8104

bonniebebodywork.com

[email protected]



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ie, scheduled meals, snacks, types of foods that they tolerate/like?
vaginal, c-section, traumas for mother and/or child that you know of before, during or after birth that you would like to share?

I have listed the conditions and limitations of my child and will inform Bonnie of any changes. I will be

present for sessions and will tell Bonnie if I feel that my child is experiencing discomfort because of

the therapy. I understand that as a massage therapist, Bonnie does not diagnose nor prescribe, nor does

she perform any spinal or joint adjustments. I will consult with my child’s physical about any physical

ailments that my child has. I consent to Bonnie Eason providing therapy that includes touching my

child in an appropriate manner.

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