Culture of Safety Shiatsu & Massage Intake Form

Shiatsu Bodywork and Massage Client Intake Form

Kyren Epperson, PhD, LMT, AOBTA®-CP
Client Health Intake

This intake form includes questions about physiological, emotional, and mental/cognitive symptoms that you may be experiencing in day to day life, in addition to your primary “complaint” or reason for seeking massage and bodywork. I ask that you fill this out to the best of your ability. All information is kept confidential. At no given point is information disclosed or shared without client’s written consent.
Name*

First NameLast Name
Pronouns

they/themshe/herhe/himOther
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Newsletter

Yes, subscribe me to this newsletter.
Occupation
Referred by:
Emergency Contact or (Legal Guardian if under 18)*

Full Name

Relationship

PhoneEmail

Address
Have you previously experienced any form of bodywork (massage, acupuncture, etc.)? If so, what?
Please describe your typical diet (or anti-diet)
Please list any medications, herbs, vitamins, and supplements you take
Do you consume any caffeine, cigarettes, alcohol, or drugs? If so how much?
Hobbies, activities, movement practices, stress-reduction activites?

Shiatsu Bodywork & Massage Policies
Client services and chart information are confidential. Written authorization is required from you to release any information.

•The session time, whether you book 1 hour, 90 minutes, or 30 minutes, includes intake and after session consultation. To save time, fill out the intake form ahead of time or arrive a few minutes early to fill it out in person.

•New clients are required to pay for their appointment at the time of booking. Repeat clients may choose to pay when they book, or pay after receiving the treatment. If you are a new client and did not pay online, I will reach out to you to receive payment to secure your appointment.

•If you cancel less than 24 hours in advance of your appointment, you will be required to pay a $50 late-cancellation fee. If you paid for a full session in advance, I can refund you the remaining balance. If you prefer to rebook, you would still pay the additional $35 for late cancellation.

•If you become ill with a cold or flu virus, please stay home. Shiatsu and other forms of massage and bodywork are contraindicated when either the client or therapist is ill. Massage can make symptoms worse and extend the duration of an illness. If you are sick, I will waive the cancellation fee so long as we rebook your appointment for another day. Likewise, if I am sick, I will rebook our appointment at no charge to you.

• Shiatsu Bodywork is performed over clothing. Please wear comfortable clothing and bring socks

• The use of substances that affect your pain-tolerance, coordination or ability to communicate will impede your ability to safely receive shiatsu bodywork and massage. This includes pain-relieving medications, cannabis, and all recreational drugs. I ask you refrain from drug use prior to your treatments unless prescribed by a medical professional.
Client Agreement & Consent to Treat
I understand that bodywork is for the well being of my body, mind, and spirit and is not a substitute for medical treatment. No guarentees or warrantees have been made to be as to the success, value, or benefit of such procedures.

Shiatsu and Therapeutic massage therapists do not diagnose illness, disease, any physical or mental disorder, nor do they prescribe medical treatment, pharmaceuticals, or perform joint mobilization. I acknowledge that massage therapy is not a substitute for medical examination or diagnosis, and it is recommended that a physician be seen for that service.

I have not promised anything to submit to these procedures, or to sign this release form.

I have read and understood the cancellation policy.

I have answered all medical questions honestly and to the best of my ability. I will update the Shiatsu/massage therapist of any changes in my health status. I understand that my failure to do so may post a threat to my health and/physical well being and I hold harmless Culture of Safety and my Shiatsu Bodyworker/therapeutic massage therapist from any liability whatsoever arising from failure on my part.

By my electronic signature below, I agree to the massage policy and client agreement above.
Patient Name*
Patient Signature *

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Shiatsu Bodywork and Massage Client Intake Form

Client Health Intake

MEDICAL HISTORY

Reason for your visit

Other Medical Information

If pain is present

Shiatsu Bodywork & Massage Policies

Client Agreement & Consent to Treat