The Mended Willow Float Waiver

New Client Information and Waiver of Liability
Date*

MonthDayYear
Date
Name*

First NameLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Do you have any serious medical conditions or allergies?*
Emergency Contact Name*
Emergency Contact Phone*
Floatation therapy provides a deep state of relaxation that stimulates blood flow through all of the body’s tissues, reduces stress hormone levels and releases natural endorphins.

I understand that floatation tanks use:

·        Pharmaceutical grade Epsom salt (magnesium sulfate)

·        Ultraviolet and Ozone sanitization systems

·        Natural and non-toxic biodegradable cleaning products

I further understand that each individual may have a unique experience. I understand I will be given an orientation which will familiarize me with the safe and appropriate use of the tank. I agree to take full responsibility for my thoughts and actions while in the floatation tank and the waiver of liability and all agreements made herein shall apply to each and every use of the floatation tank.

I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against The Mended Willow, LLC and its employees and agents. I will not hold the owner/operator of The Mended Willow, LLC nor its employees and/or agents liable for any injury during a session or while on the premises.
To ensure a comfortable, clean and safe floatation experience, I agree to the following (Please check each statement below to show you will abide by the conditions set forth):*

Minors are not permitted to participate in floatation therapy. I certify that I am at least 18 years old.All float tanks are in wet areas and I will take extra precautions for my own safety. I assume any and all liability due to injury and/or damage resulting from any slip and fall incident.I am physically capable of getting in and out of the float tanks on my own. This requires enough upper body strength to pull myself up from a sitting position to a standing position. If unable, I agree that I will arrive with a certified aide to help me in and out of my session.If this is my first time floating, or if I require a refresher orientation, I will arrive 15 minutes prior to my appointment time. Otherwise, I will arrive 10 minutes prior to my scheduled float session.I agree to shower with body wash and shampoo thoroughly before each of my float sessions to completely remove all dirt and oils from my body.I am aware that keratin hair treatments can be affected by any salt water, especially the highly saline water in a float tank.I agree that any cologne, perfume, make-up or creams will be fully removed from my body prior to entering the float tanks.I agree that, if I smoke, I will refrain from doing so for at least one hour prior to entering the float center to avoid brining the odor of smoke into the tanks.If pregnant, I have consulted with, and secured written permission from my physician to float.If I have had ear surgery, I have consulted with, and secured written permission from my physician to use the floatation tank. Clients with ear tubes are not recommended to float.I understand that, in order to keep other customers from waiting, my showering times should be limited to no more than 10 minutes each.I do not have any communicable or infectious disease, illness, or skin disorders.I do not suffer from incontinence.If I suffer from uncontrolled seizures or epilepsy, I have medical authorization to float.I do not have a condition nor am I on any medication which may have adverse effects due to immersion in the concentrated magnesium sulfate (Epsom salt) water solution.I understand that floating may lower blood pressure and will take extra care standing up after my float. If I have a history of high or low blood pressure, I have medical authorization to float.I understand that if I suffer from vertigo when lying down, the same could occur during a float session.If I have chronic heart or kidney disease, I have medical authorization to float.If I am diabetic with insulin dependency, I have medical authorization to float.I am not under the influence of any medication, drug or alcohol.
** If it is found that any of the preceding conditions were agreed to untruthfully and/or were not adhered to, The Mended Willow, LLC reserves the right to cancel an appointment without a refund or to ask a guest to reschedule.
Hair Dye and Liquid Tanning or Other Contamination of the Float Tank Solution

Hair dye and self-tanners has been shown to cause many incidents of float tank solution discoloration. The leeching of the dye out of the hair can permanently stain the float tank interior, stain our towels and can be almost impossible to remove from the solution without a full replacement of the water and salt. If you dye your hair, please make sure the dye is fully set (usually about 30 days). You also agree that you have not used a self-tanner or had a professional spray tan in the past 7 days.

Violation of any of the rules above resulting in contamination of the float tank solution (including but not limited to dyes, oils or any bodily fluids/excrement) will result in a cleaning, loss of business and/or salt replacement fee of $1500.
The Mended Willow - Cancelation and No Show Policy

Cancellations must be made more than 24 hours before the appointment time. Cancellations made less than 24 hours before the appointment time will result in a 50% charge of the original appointment fee being charged to the card on file. No call or no shows will result in the full charge for the original appointment being charged to the card on file.

By agreeing to the statement below you are acknowledging and understand you could be responsible and charged for any damages caused during your visit or for any cancelled or skipped appoinments per the poilicies outlined above.
The Mended Willow - Credit Card on File

Due to the nature of our business we require our customers to keep a credit or debit card on file. You will not be charged anything to your card when you enter the information below. Your card information is stored securely in our system and no charges are assessed until the day of your scheduled appointment. You may pay with cash or a different method during your visit in lieu of the card on file.
Card Type*
Name on Card*

First NameLast Name
Credit Card Number*
Card Security Code*
(usually a 3 digit number on the back)
Card Expiration*

2 Digit Month4 Digit Year
Billing Zip Code*
Credit Card Authorization(Please check the statement below to show you will abide by the conditions set forth):*

I authorize The Mended Willow to charge my credit card for agreed upon services. I understand that my information will be saved to file for future transactions on my account. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled..
I understand that:

·        The Mended Willow, LLC reserves the right to refuse service to anyone.

·        I am choosing to use floatation therapy of my own free well and will not hold the owner/operator or The Mended Willow, LLC liable for any injury during a session or while on the premises.

·        The floatation tank contains Pharmaceutical grade Magnesium Sulfate and Water, and that some may experience skin allergies, discomfort or other reactions to this solution.

·        This signed document represents an agreement between us, which you may revoke in writing at any time.

I understand that the float tank solution is not discarded between floats, but is filtered, sanitized and recycled; that our tanks are inspected between every float; and that violation of any of these rules that results in contamination of the float tank solution may result in a cleaning or salt replacement fee of $200-$1500.

Only a trained medical professional can provide diagnoses or give medical advice. Float therapy tanks are generally safe. When it comes to your health or specific medical concerns you should always consult with a trusted medical physician to gain written permission to float. They can assess your circumstances and provide accurate information regarding any potential risks or interations related to float therapy and your specific needs.

I have read and fully understand and agree to the above terms of this liability waiver agreement. I am signing this agreement voluntarily and recognize my signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Pennsylvania. By signing below you agree that you have read it in its entirety and fully understand The Mended Willow, LLC waiver and release form.
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New Client Information and Waiver of Liability