Confidential Client Intake Form

General Questions:
Occupational Questions:
Medical History
Check any or all that apply to your present health
Women Only

To comply with informed consent I will discuss the following with you prior to your treatment:
1. What to expect from your Ashiatsu treatment
2. Proposed treatment plan and goals
3. Explanation of analog pressure scale I will be using during your treatment
4. Any contraindications or precautions for receiving Ashiatsu massage


Please take a moment to carefully read the following information and check the signature to accept above

I understand that the massage/bodywork I receive is provided for basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for an examination, diagnosis or treatment of disease/injuries. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there should be no liability on the practitioner’s part should I forget to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in termination of the session, and I will be responsible for payment of the scheduled session. I agree and adhere to the cancellation policy set forth and will be responsible for charges if I fail to show for my scheduled appointment.