Massage Therapy Client Intake

Client Intake Form - All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.

Please note if you choose to provide your email, you will be added to our e-newsletter distribution list.

Full Name*

First NameMiddle NameLast Name

Today's Date*

Date

Occupation

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date

MonthDayYear

Phone Number*

Format: (000) 000-0000.

E-mail

example@example.com

Emergency Contact

Phone Number

Format: (000) 000-0000.

How did you hear about Botanique?

Medical Conditions (please list anything your therapist needs to be aware of including recent surgeries, autoimmune diseases, treatment for disease, etc)

Do you have any known allergies to oils, tints, waxes or other skincare products?

Is there a part of the body you prefer to not have touched today such as scalp, feet or hands?

Medications

Other Allergies

Please complete this section if you are having MASSAGE today

List Areas of Discomfort or Pain and/or areas you would like the therapist to focus on

Will you be requiring a private health fund rebate for your massage treatment today?

Describe when pain is most noticeable (ie during which movement, sleep, etc)

Is the pain/condition as a result of an injury? If so, please describe.

Please complete this section if you are having FACIAL OR BEAUTY TREATMENTS today

What are your skin concerns?

Would you describe your lifestyle as 'healthy' ie do you exercise regularly, eat healthy, non smoker, moderate drinker, etc?

What skincare products are you currently using?

Are you interested in having a thorough skin consultation including discussion about products and treatment options?

Waivers & Agreement Section (please INITIAL each section where indicated)

COVID & OTHER INFECTIOUS DISEASES: Please initial here to acknowledge you are not current suffering from potential CoVid or other contagious symptoms including fever, dry cough, runny nose, shortness of breath; further that your decision to receive services is voluntary, and you understand and assume any and all the risks associated therewith including exposure to any potential contagions. You may be asked to use a hand sanitizer prior to your treatment commencing. We ask that you cover your nose and mouth if you need to cough or sneeze with a tissue or your elbow. PLEASE NOTE THAT WHILST WE ARE TAKING ALLPRECAUTIONS NECESSARY TO ENSURE OUR CLINIC REMAINS FREE OF ANY CONTAGIONS, THE ONUS IS UPON YOU TO LET US KNOW IF YOU ARE CURRENTLY FEELING UNWELL. FURTHER YOU MAY BE ASKED TO RESCHEDULE IF DEEMED APPROPRIATE. *

FURTHER IF YOU HAVE RECEIVED A COVID VACCINATION, YOU ARE REQUIRED TO WAIT 72 HOURS AND ENSURE YOU ARE NOT EXPERIENCING ANY SIDE EFFECTS BEFORE HAVING ANY TREATMENTS. A doctor’s certificate may be required. *

CLIENT AGREEMENT: I hereby consent to receiving services from Botanique Skin Wellness Spa. To my knowledge, I have no medical conditions or allergy which would preclude me from having the selected procedures performed. I agree not to hold Botanique Skin & Spa responsible for any and all medical complications that may arise. I have been advised to discontinue use and consult a physician if any reaction occurs. I agree not to hold Botanique Skin Wellness Spa responsible for any and all damage or loss of personal items. I, the undersigned agree to and understand the following:• I have understood all of the instructions & procedure details given to me prior to the session.• I understand that I am responsible for all jewelry, clothing, accessories I wea rbefore & after my session.• While allergic reaction is rare, I assume responsibility for any kind of allergic reaction I may have and will seek immediate medical attention. I understand Massage therapy is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I have. I understand that the massage therapist does not prescribe medical treatments or pharmaceuticals, and does not perform any spinal adjustments. I am aware that if I have any serious medical diagnosis I must provide a physician’s written consent prior to services. Draping will be used during the massage session. If uncomfortable for any reason the client or therapist may ask to end the massage session, and the session will be ended. All services are purely therapeutic and non-sexual. *

CANCELLATION POLICY - We will always do our best to accommodate any situation where you may need to reschedule or cancel your existing appointment, however due to the number of no shows and the fact that staff are on site specifically for client appointments, the following cancellation policy will be enforced: LESS THAN 24HOURS NOTICE OF CANCELLATION (with notice by message) :$25 LATE CANCELLATION FEE WILL APPLY. NO SHOW: 50% OF APPOINTMENT COST IS PAYABLE .*