Floatation Tank Consent Form

Floatation Tank Consent Form

Liability Waiver and Professional Agreement At Northern Arizona Massage Therapy, we make all reasonable efforts to ensure a comfortable, clean and safe environment. To ensure you have a safe and comfortable floating experience, please read the following guidelines and sign your name. This form is mandatory and required to be completed prior to any services being offered.
Basic Information
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Consent Form and Guidelines
PLEASE READ THE FOLLOWING INFORMATION AND ACKNOWLEDGE THAT YOU UNDERSTAND AND ACCEPT ALL PROVISIONS BY SIGNING BELOW.

It is our intention to keep you as well informed as possible. This means informing you how to operate the equipment. The proper procedure to follow will be clearly explained by a member of our staff. Please feel free to ask any questions.
I, the willing customer, will NOT use the float pool if:
- I have not showered thoroughly and still have oils, creams, or makeup on my body.*
- I have had any type of hair color/treatment within the past two weeks.*
- I am under the influence of alcohol or drugs.
- I have a communicable or infectious skin condition, disorder, or diseases.
- I have open sores.
- I am pregnant and have NOT consulted and received permission to float from my heath-care provider
- I am diabetic, unless my diabetes is under medical control.
- I have a history of heart trouble, epilepsy, seizures or blackouts and have not received my doctor’s permission to use the floatation tank.
- I am experiencing a heavy menstrual period and menstrual blood could come out into the water.*
- I have a condition which may be adversely affected by cutaneous absorption of magnesium.
- I have kidney disease.
- I suffer or have suffered from any claustrophobic or small or enclosed space anxiety-provoking disorders
- I may release bodily fluids, voluntarily or involuntarily, into the float pool.*
* I understand that violation of any of these above rules that results in contamination of the float pool water may result in a cleaning and salt replacement fee of up to $1,000.
I, the willing customer, UNDERSTAND and AGREE to:
- I agree to the mandatory 5-minute shower (full shampoo and body scrub) prior to and after floating, even if I have just showered prior to arrival.
- I agree to only use the soap and body wash provided prior to floating. Contamination of the spa water with outside products, bodily fluids, hair dye, etc. is my financial responsibility.
- No one under the age of 18 is permitted in the float tank unless approved of by a supervising adult.
- It is up to each individual to take caution to prevent slipping or falling as the floor surfaces will be wet.
- I understand that if I have shaved or waxed within 48 hours, there may be irritation from the chemicals inside the float tank.
- I understand that using any self-tanning products must be complete at least 72 hours prior to floating
- I am physically capable of getting in and out of the float pod on my own.
- I further understand that the floatation tank uses Epsom salt (U.S.P. pharmaceutical grade magnesium sulfate) and hydrogen peroxide cleaning products which will be in the water and that some people may experience skin allergies or reactions to such chemicals
- I also hereby agree and understand that I shall have consulted with my own health care provider prior to using the flotation tank if I am currently taking any medication or under a physician’s care for any reason
- Upon using this floatation room, I absolve NORTHERN ARIZONA MASSAGE THERAPY, LLC, employees and agents from any and all liability in connection with the use thereof whether such loss or damage is direct or indirect
- I am choosing to use the floatation spa of my own free will and agree not to hold the facilities, operators or owners liable for any injury to self or for loss/damage of personal items
By signing below, I have read and understand the above statements and agree to comply with the rules of this facility.*

Clear
Date*

MonthDayYear
Date
Parent / Legal Guardian Permission for Minors
I ,First Name Last Name , HEREBY GIVE MY PERMISSION AS A PARENT/GUARDIAN of First Name Last Name who is years of age to float at this facility.
I have read and fully understand this Client Release and Informed
Consent Form and hereby agree to accept all of the provisions.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Floatation Tank Consent Form

Basic Information

Consent Form and Guidelines

Parent / Legal Guardian Permission for Minors