SOMA CURA WELLNESS CENTER

SOMA CURA WELLNESS CENTER
2154 Grand Island Blvd.

Grand Island, NY 14072

(716)773-1369

www.somacura.com
Far Infrared Sauna Intake & Waiver
Far Infrared (FIR) Sauna Therapy is an outstanding treatment modality and relaxation therapy for a great many people. There are, however, some people who should not use FIR sauna at all and others who should use it with caution. The following check list helps you identify any considerations specific to you and requests you acknowledge and accept the risks inherent in the use of the Far-infrared Sauna.
Full Name*
Phone Number*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Emergency Contact Name*
Emergency Contact Phone Number*
How Did You Hear About Us
Have you used FIR sauna before?*

YesNo
Contraindications
Are You Pregnant?*

YesNo
Do you currently have a fever, infection or injury?*

YesNo
Have you recently had uncontrolled blood pressure, a heart attack or other cardiovascular problem?*

YesNo
Do you have a history of dizziness, fainting spells, heat sensitivity, narcolepsy or seizures?*

YesNo
Do you suffer from any bleeding disorders?*

YesNo
If you answered Yes to any of these questions it is NOT recommended that you use the infrared sauna at this time. We suggest that you consult your Primary Health Care Physician to obtain a release form in order to utilize the Far Infrared Sauna
Cautions:
Have you been diagnosed with any other medical condition?*

YesNo
If yes, which condition(s)?
Have you consulted your doctor regarding your ability to use the far infrared sauna due to this condition?

YesNo
Are you on any medications?*

YesNo
If yes, Have you consulted your doctor regarding using the infrared sauna? (It is recommended that you talk with your doctor before using the infrared sauna).

YesNo
- The use of drugs, medications, or alcohol prior to or during the sauna session may lead to dizziness or unconsciousness.
- No one under the age of 18 is permitted in the far infrared sauna unless accompanied by a supervising adult.
- Older patients should consult their physician before using the infra red sauna.
- Discontinue the use of the sauna if you feel light-headed, dizzy or heat exhausted.
Recommendations
- Sauna sessions should be limited to no more than 45 minutes and temperatures must stay below 150 degrees Fahrenheit.
- It is always important to maintain proper hydration levels during far infrared therapy. Dehydration will actually increase carbohydrate utilization and cause less fat to be burned for energy.
- We highly recommend drinking a minimum of 4 oz. of water prior to entering the sauna and a minimum of 8 oz. of water after sauna use. Please consult your physician if you are in doubt regarding your ability to use the far infrared sauna for health reasons.
I acknowledge and accept the risks inherent in the use of the Far-infrared Sauna. I voluntarily assume the risk of injury, accident or death, which may arise from the use of the Far-infrared Sauna. I and any of my heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal injury or property damages of any kind sustained while on the premises, during the use of the Far- infrared Sauna and from any advice provided by an employee, independent contractor or any representative. I agree that this Application and Waiver is in effect for all Far-infrared Sauna sessions and will not expire unless requested by either party. Soma Cura Wellness Center, and its representatives do not provide medical advice or treatment. Far-infrared Sauna use may or may not be appropriate for you. Please consult your health care provider for medical advice. The information provided is for general information purposes only and does not address individual circumstances or medical conditions. Do not attempt to self-treat any disease with a Far-infrared Sauna.
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SOMA CURA WELLNESS CENTER

Far Infrared Sauna Intake & Waiver

Contraindications

Cautions:

Recommendations