Release of Information Form

CONFIDENTIAL CLIENT INTAKE FORM - INFRARED SAUNA.

The Clearlight® Sanctuary Infrared Saunas is a cutting-edge far infrared sauna that provides a wealth of health benefits. Traditional saunas use convection heating, which heats the air around you and can cause you to feel hot and sweaty. However, far infrared saunas use radiant heat to directly penetrate your body tissue. This delivers a deep, detoxifying sweat at the cellular level, flushing toxins and impurities from your body, as well as a host of other wellness benefits. Get the ultimate sauna experience with Clearlight!
1. Please reschedule if you have been unwell in the past 7 days; this is apart of our general onsite infection control policy at Broulee Health Hub.*

YES ( I have been unwell & will call to reschedule, call us at 0415 567 439).NO ( I am well and will be attending my Sauna appointment!).Other
2. We are a business and late cancellations (within 24 hours) need to be accounted for. If you are a member or have an eGift card, we will still require your Credit or Debit card details to secure your appointment(s) online, no amount is withdrawn from your card when booking in online. We have implemented a 50% cancellation fee policy to ensure that we are no longer at a loss when people fail to show up or give reasonable notice prior to their appointment time. This 50% fee will only be charged from the card details you provided when booking in, if you cancel within 24 hours.*

Yes, I understand.Other
3. Name*

First NameLast Name
4. Birth Date*

DayMonthYear
5. Phone Number & Occupation*
6. Are you attending this Sauna Session as a '$15 Sauna Buddy' with a current Broulee Massage Member? If so, please list the members full name in order to have this discount applied (i.e. Yes, I am attending a Sauna session with member: John Smith) If no, N/A.*
7. Are you attending this Sauna Session as a person nominated as a co-member of a Broulee Massage Member? (If yes, please list the full name of the member in order to have your treatment verified) If no, N/A.*
7a. Are you a member of 'The Quest' via Metamorph Mobile Health & Fitness?*

Yes (Thanks! We'll cross check your name from the list).Not applicable.
8. Medical Emergency Contact Name, their relation to you & their contact number*
MEDICAL HISTORY
1. Do you have or are you undergoing any of these conditions/treatments currently/recently/ongoing?*

Abnormal bleedingAIDSAlcohol abuseAnemiaAnxietyArthritisAsthmaBalance lossBreast ImplantsBlood clots/disorderCardiovascular ConditionsChronic ConditionsCancerTinnitusCold extremitiesChemotherapyChest painsDepressionDiarrhoeaT1 diabetesT2 diabetesDizzinessEpilepsyFacial surgeryFeverFaintingChronic fatigueHeart attackHeart problems / anginaHeatstrokeHeat SensitivityHepatitisHigh blood pressureInfectionsLimited Range of MotionLow blood pressureMuscle stiffnessMemory lossNumbnessOpen WoundsPacemakerPregnantPostpartum (birth was within last 12 months)PTSDSunburnSeizuresShinglesSinus problemsStressVaricose veinsNONE OF THE ABOVEImplanon RodOther
1a. If you selected any of the conditions above, please provide us with more information below (i.e. HIGH BP - under control). If none - please type: N/A*
2. Do you have any additional disease(s), condition(s), injury or problems that you feel we should know about/are not listed above? If yes, please list & describe. If no, please type: N/A*
INFRARED SAUNA RULES (PLEASE CHECK ALL BOXES BELOW)*

I understand the requirement to hydrate with drinking the water provided prior, during & after infrared sauna use.I will remove all bulk jewellery including rings, watches, bangles etc before entering the sauna.I understand for sauna effectiveness I should remove makeup/lotion/sunscreen/zinc from my skin prior to entering the sauna. Please use makeup wipes + shower + body wash provided.I understand that no food or drink is permitted inside the sauna cabin.I will wear swimwear bottoms/shorts at all times in the sauna. I will sit on a towel at all times in the sauna.I will dry off completely if I shower before entering/re-entering the sauna.I understand the temperature touch pad does not need to be adjusted, I will open the sauna door to adjust cabin temperature.I understand not to engage in infrared sauna therapy if I have had prolonged sun exposure/are sunburnt.I understand I need to be fully dressed at all times if I need to exit the Sauna room to use the bathroom; please be courteous of other staff & clients within the Health Hub.I understand that vigorous activity & exercise is not permitted inside the sauna.I understand not to engage in infrared sauna therapy if I am pregnant/possibly pregnant or have uncontrolled high blood pressure or heart disease or diabetes.I understand not to engage in infrared sauna therapy if I have any open sores/cuts or wounds (for minor cuts please ask for a bandaid/bandage).I understand not to engage in infrared sauna therapy if I am unsure about anything & should seek medical clearance from my doctor/GP.I understand I will always have a staff member assigned to my session if I have any questions or need assistance during my sauna session.
INFRARED SAUNA USE CLIENT CONSENT.

Please read the disclaimer thoroughly.
I, (please print/type your full name): *
Please read this waiver and disclaimer form carefully before using the Clearlight Infrared Sauna at Broulee Massage + Broulee Health Hub. By signing this form, you acknowledge that you have read, understood, and agreed to the following terms and conditions: Health Considerations: The Clearlight Infrared Sauna is not intended to diagnose, treat, cure, or prevent any disease. It is essential to consult with your healthcare provider before using the sauna, especially if you have any medical conditions or concerns. Pregnant women, individuals with cardiovascular conditions, hypertension, diabetes, or other medical conditions should seek medical advice before using the sauna. If you experience any unusual symptoms during or after sauna use, such as dizziness, nausea, shortness of breath, or discomfort, stop using the sauna immediately and seek medical attention. Risks and Precautions: The use of the Clearlight Infrared Sauna involves exposure to infrared heat, which can cause excessive sweating and an increase in body temperature. Ensure that you stay properly hydrated before, during, and after the sauna session. Use caution when entering and exiting the sauna to prevent slipping or falling. Do not bring electronic devices or liquids inside the sauna. It is recommended to limit sauna sessions to a reasonable duration, typically 15-30 minutes, depending on your tolerance level. Release of Liability: I voluntarily assume all risks associated with the use of the Clearlight Infrared Sauna and release Broulee Massage + Broulee Health Hub and its representatives from any liability for any injury, loss, or damage that may occur during or after the sauna session. I agree to indemnify and hold harmless Broulee Massage + Broulee Health Hub and its representatives from any claims, damages, or expenses arising out of my use of the sauna. Privacy and Confidentiality: Broulee Massage will keep all personal information provided in this form confidential and will not share it with any third parties without explicit consent. I have read, understood, and agree to the terms and conditions outlined in this waiver and disclaimer form. I confirm that I am using the Clearlight Infrared Sauna at my own risk and that I have sought medical advice if necessary. I understand that there may be an associated risk with any therapeutic intervention. 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 behaviour from the client. I understand that Broulee Massage + Broulee Health Hub 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 or Sauna Session.
Yes, I do consent to the above information:*

YesOther
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CONFIDENTIAL CLIENT INTAKE FORM - INFRARED SAUNA.

MEDICAL HISTORY

INFRARED SAUNA USE CLIENT CONSENT.