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*

YES ( I have been UNWELL & will call to reschedule 0415 567 439).NO ( I am WELL and will be attending my massage appointment).

2. Broulee Massage have made the decision to implement a 50% late cancellation fee. Please keep in mind that 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.

3. Name*

First NameLast Name

4. Birth Date*

MonthDayYear

5. Phone Number & Occupation*

POST CODE

eGift Cards: Will you be using a Gift Voucher at the time of your treatment? If so, please bring with it with you (printed copy OR phone display) and also enter your gift voucher code here below.

Email

example@example.com

Medical Emergency Contact Name, Relation to you & their Contact Number*

I am Pregnant:*

Yes (please stop filling out this form and contact Broulee Massage to be sent the appropriate Pregnancy Massage form as soon as possible).No

1. Are you taking any medication?*

YesNo

If yes, please list -

2. What is your gender?

FemaleMale

3. Do you have any allergies, recent surgeries or had recent injuries (within last 5-10 years)? Please be aware that if you mention a condition in your verbal consultation that you forgot to put in this form; this could result in a referral to another practitioner on the day (such as a Physio or GP) so please be honest and thorough in this form so we can determine the safest treatment plan for you before the time of your appointment.*

Yes (please list below and approx. year).No (I have had no injuries, allergies or surgeries within last 5-10 years).

If yes, please list (i.e. surgery, 2010 laparoscopy) -

4. Please describe your optimal treatment outcome for your upcoming massage appointment and your preferred massage application pressure (i.e. Full body Relaxation massage with a medium pressure).

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

6. 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*

7. 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*

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:*

Yes

Signature

Clear

BROULEE MASSAGE. CONFIDENTIAL - CLIENT TREATMENT FORM

MEDICAL HISTORY

MASSAGE & CUPPING CONSENT