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Consent and Terms Waiver

This general waiver outlines important terms and conditions you agree to before using our services.

Body Detox Massage

General Instructions

If you suffer from any of the following illnesses, please contact us before booking, as you may not be able to have this treatment:

Acute infection (viral, bacterial, open wound, bronchitis)
Acute Venous Disease
Cardiac Oedema
Malignant Disease

Your health is our priority.

Please fill out the following details.

First name

Last name

Email

Phone

Birthday

Day

Month

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

How did you hear about us?*

What is your Occupation?*

Primary reason for visit (Identify specific area of pain or discomfort)*

Indicate the level of pain you are experiencing*

Do you have any allergies?

Are you pregnant?*

Yes

No

Do you suffer from any of the following?*

Do you have any serious illness including cancer, heart disease, blood clots or other?*

Yes

No

Do you have any metal implants?

Yes

No

Have you had a cosmetic procedure in the last 30 days? (If yes, please give details below)

Please list any surgeries that may be relevant to your appointment.

Are you taking any medications? (If yes, please give details below)

Please tick if you have any of the following symptoms/conditions (past and present)

Allergies

Cancer

Dental Fixtures

Diabetes

Fatigue, C.F.S

Headaches, Migraines

A.I.D.S., HIV

Infectious Condition

Kidney Problems

Stress

Vision Problems

Arthritis

Artificial Bones

Carpal Tunnel Syndrome

Jaw Pain, Tmj Syndrome

Joint Replacements

Muscle or Joint Pain, Injury

Osteoporosis

Sprains, Strains

Asthma, Lung Condition

Breathing Difficulty

Cold, Flu

Sinusitis, Sinus Problems

Eczema

Fungal Infection

Psoriasis

Rash

Blood Clots

Heart Problems

High/low Blood Pressure

Poor Circulation

Swollen Ankles

Varicose Veins

Depression

Dizziness

Epilepsy

Numbness, Tingling

Sciatica

Sleep Difficulties

Abdominal Pain

Constipation

Diarrhoea

Digestive Disorder

Irritable Bowel Syndrome

Other

Are you currently under the care of a health care professional? (Please provide name and contact number)

Emergency Contact Name*

Emergency Contact Number*

How do you prefer the pressure of your massage?*

Firm

Medium

Light

I agree that Lymph & Glow is not liable for any injuries or side effects during or after treatment.

I consent to undertake non-invasive body sculpting treatments using both devices and manual techniques which can include Wood Therapy and Lymphatic Drainage Massage.

Gentle Lymphatic Massage

©2026 by Lymph & Glow

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admin@lymphandglow.com.au

30 Berghofer Drive, Withcott QLD 4352

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