Soteria Wellness Massage and Bodywork Informed Consent Form
I, _____________________________________ (client, please print), understand that massage
and bodywork (CranioSacral Therapy, lymphatic drainage, or other technique) provided by
Dawn Olsen of Soteria Wellness, LLC is intended to enhance relaxation, reduce pain caused by
muscle and other soft tissue tension or restrictions, increase range of motion, improve
circulation, and offer a positive experience of touch.
The general benefits of massage and bodywork, possible contraindications, and the treatment
procedure have been explained to me. I understand that massage therapy and bodywork is not a
substitute for medical treatment or medications, and that it is recommended that I concurrently
work with my primary caregiver for any condition I may have. I am aware that the massage
practitioner/CranioSacral Therapist does not diagnose illness or disease, does not prescribe
medications, and that chiropractic spinal adjustments are not part of massage therapy.
I have informed my massage therapist/bodywork practitioner of all my known physical
conditions, medical conditions, and medications (including herbal remedies and supplements),
and I will keep the practitioner updated on any changes that occur.
I agree to obtain a medical release if required by my therapist for any specific health conditions.
I realize that I have the right to refuse, modify, or terminate massage therapy or bodywork
treatment at any time.
I understand and agree that my practitioner has the right to terminate any session and refuse
further treatment for inappropriate requests or suggestions of a sexual nature.
Client Signature: ________________________________________Date: _________________
Appointment Reminder Permission
I hereby give Soteria Wellness, LLC permission to contact me by phone with an appointment
reminder prior to any further scheduled appointments.
Client Signature: ________________________________________Date: _________________
Mail/Email Permission
I hereby give permission for Soteria Wellness, LLC to contact me by mail and/or email with
occasional newsletters, upcoming events, or special offers. Soteria Wellness does not share or
sell mailing lists.
Client Signature: ________________________________________Date: _________________
Email Address: ________________________________________________________________
Consent to Treatment of Minor/Dependent
By my signature, I hereby authorize Dawn Olsen of Soteria Wellness, LLC to administer
massage and/or bodywork techniques to my child or dependent as they deem necessary for the
purposes listed above.
Parent/Guardian Signature: ____________________________________Date: ____________
Consent to Treat During Pregnancy
Due Date: __________________________ Is this your first pregnancy? __________________
Doctor/Midwife: ___________________________________Phone: ______________________
Do you have your provider’s approval to receive massage? ______________________________
Please answer the following by circling Yes or No as appropriate for each question:
YES NO
Have you had any recent morning sickness, vomiting, diarrhea, or fever?
YES NO
Have you noticed a reduction in fetal movement during the past 24 hours?
YES NO
Have you had excessive swelling in your arms, legs, hands, feet, or face?
YES NO
Do you have poor circulation and/or varicose veins in your legs?
YES NO
Have you been, or are you currently, inactive or placed on bed rest?
YES NO
Have you experienced any vaginal bleeding or abnormal discharge in the last 24
hours?
YES NO
I am having a normal, healthy pregnancy.
I have disclosed all medical conditions in writing, either on this form, or the Health History Form
I have completed. I understand that massage therapy or bodywork administered by Dawn Olsen
of Soteria Wellness, LLC is not a substitute for prenatal medical treatment or counsel. To reduce
my risk of any potential prenatal complications it is imperative that I consult my primary health
care provider and/or midwife during my pregnancy. I request that Dawn Olsen of Soteria
Wellness, LLC administer massage therapy and/or bodywork for the purposes of stress
reduction, relaxation, and relief of minor pregnancy discomforts.
Client Signature: __________________________________________Date: _______________
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Soteria Wellness Massage and Bodywork Informed Consent Form