BROULEE MASSAGE. CONFIDENTIAL - RETURNED CLIENT TREATMENT FORM.
This form is to ONLY be filled out if your last appointment was within the last 3 months. If your last appointment with Broulee Massage was longer than 3 months ago - please exit this form and fill out the 'NEW CLIENT' form. Please note - you are required to CANCEL your upcoming Massage appointment as soon as possible if you are showing ANY signs of feeling unwell before your treatment i.e. loss of taste or smell, shortness of breath, a fever, a runny nose, a sore throat, a cough, a fever and or/ flu-like symptoms, vomiting, diarrhoea & headaches etc.
1. If it has been longer than 3 months OR you are now postpartum since your last visit to Broulee Massage - please EXIT from this form and complete the 'NEW CLIENT' consultation form to help keep us up to date with your current health status.
Yes - it has been longer than 3 months since my last visit to Broulee Massage, I will exit this form and complete the 'NEW CLIENT' online consultation form.
No - I have visited within the past 3 months and am a return client completing the relevant Return Client Infection control questionnaire only prior to my treatment.
2. Please reschedule if you are currently or have been unwell in the past 7 days; this is apart of our general onsite infection control policy (Covid, Influenza, Gastro etc - please cancel).
YES ( I have been unwell recently & will call Broulee Massage to reschedule 0415 567 439).
NO ( I do not need to reschedule, I am well and will be attending my upcoming appointment).
3. Please be aware Broulee Massage have implemented a 50% late cancellation fee. We are a business and that late cancellations (within 24 hours) need to be accounted for. If you are on a pre-paid massage package or have an eGift card, we will still require your Credit or Debit card details to secure your appointment(s) online from now on. We have implemented a cancellation fee to ensure that we are no longer at a loss when people fail to show up or give reasonable notice prior to their appointment.
Yes, I understand.
5. Do you need to update your contact mobile number or medical emergency contact person and their number since your last visit?
No, my contact number and medical emergency contact person have not changed since my last appointment with Broulee Massage.
Yes, please update & add these new details to my client file (please enter your new contact info in the space provided below).
I'm unsure (if you're unsure please add your mobile number and emergency contact person and their best contact number in the space provided below).
5a. New contact details for updating:
6. Please describe your optimal treatment outcome for your upcoming Massage appointment with Broulee Massage (i.e. Full body Massage, feel relaxed with focus on feet & scalp).
7. If you have had a recent illness, have an injury or recent surgery since your last appointment with Broulee Massage, we need to know! Please exit this form & complete the 'NEW CLIENT' form - this keeps us compliant with our businesses record keeping policy
Yes (I agree, there are no recent changes to my medical health history since my last appointment with Broulee Massage).
No (I disagree, I need to exit this form and complete the 'NEW CLIENT' form to update my current health status i.e. recent injury, surgery, operation, illness, new allergies etc).
MASSAGE & CUPPING CONSENT
Please read the disclaimer thoroughly.
I, (please print/type your full name):
understand that there may be an associated risk with any therapeutic intervention. I understand this is a massage clinic and not a medical practice and that a consultation process reviewing my health history is required before treatment begins. Please note: your therapist is sensitive to cigarette smoke and perfumes/colognes - please refrain from having a cigarette at least 2 hours before treatment and regarding personal hygiene a basic underarm deodorant is more suitable over perfumes/colognes. I understand that the therapist will determine a therapeutic strategy that is appropriate to my needs and also within the bounds of the practitioners scope of practice. The practitioner will explain the proposed therapeutic strategy and treatment plan to me and my consent to this plan will also be sought verbally. Instructions about the massage procedures, areas of the body being treated, draping, positioning on bed and undressing procedures will aim to be discussed in consultation prior to the therapist leaving the treatment room to provide privacy to the client before commencing treatment. I understand that I can request adaptations to the pressure of any massage techniques being applied during any stage of the treatment. There may be risks of infection that occur between practitioners and their clients. These risks cannot be eliminated due to incubation periods that prevent people from knowing their infectious status. Infection control strategies are in place to protect both clients and practitioners in this clinic. I understand if I have any questions that I can ask my therapist/practitioner. I understand that there are some risks with any form of care. I understand that I will honestly discuss any risks with my practitioner and that I will be given the opportunity to ask questions beforehand and ensure that I am satisfied with the answers before commencing treatment. I understand that I can choose to cease treatment at any time. I understand that my therapist can choose to cease treatment at any time deemed any inappropriate behavior from the client. I understand that Broulee Massage is not a sexual service. I understand that my therapist has the right to cease treatment if they suspect that I am under the influence of Drugs or Alcohol at the time of the treatment. I grant permission for a therapist from Broulee Massage to perform a treatment on me.
Yes, I do consent to the above information:
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