Release of Information Form

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.

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eGift card, we will still require your Credit or Debit card details to secure your appointment(s) online, no amount is withdrawn from your card when booking in online.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.

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?

8. Medical Emergency Contact Name, their relation to you & their contact number

1. Do you have or are you undergoing any of these conditions/treatments currently/recently/ongoing?

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, (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:

Other

Signature

CONFIDENTIAL CLIENT INTAKE FORM - INFRARED SAUNA.

MEDICAL HISTORY

INFRARED SAUNA USE CLIENT CONSENT.