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  • Client Intake & Waiver Form

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Session Type:*

  • CLIENT INFORMATION

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • WELLNESS SCREENING

  • Do you have any of the following conditions? (Check all that apply)

  • If you checked ANY boxes above, you should consult with your primary doctor before participate in our alternative services (halotherapy, red-light therapy, etc.). 

  • INFORMED CONSENT & WAIVER

  • I understand and agree to the following:
  • 1. Nature of Service: Salt therapy (halotherapy) is a natural, holistic wellness service that is NOT a medical treatment and is NOT intended to diagnose, treat, cure, or prevent any disease. Red-Light Therapy is the only alternative wellness service we provide that's FDA approved.
  • 2. Medical Clearance: Mobile Saltworks do not provide medical advice or diagnosis. Clients should consult with their doctor before and/or after a salt therapy experience.
  • 3. Possible Effects: I may experience temporary coughing, dry throat, nasal drip, thirst, or minor skin sensitivity as my respiratory system clears. These are normal responses.
  • 4. Voluntary Participation: My participation is completely voluntary. I am responsible for my own wellbeing and any children/guests with me.
  • 5. Assumption of Risk: I understand salt therapy involves inherent risks and I voluntarily assume all risks associated with participation.
  • 6. Mobile Rules: I agree to follow all rules before, during, and after sessions including: arrive on time, placing electronics and personal items in overhead bin, wearing disposable socks or shoe covers (provided by Mobile Saltworks) inside the EV Salt Cave, respect cancellation policies, and handle all equipment (VR headsets, massage chairs, headphones, etc.) with care. I am responsible for any damage caused by misuse or negligence.
  • 7. Release of Liability: I HEREBY RELEASE, WAIVE, AND HOLD HARMLESS Mobile Saltworks, its owners, employees, and agents from any and all claims, liabilities, damages, or injuries arising from my participation, including those resulting from ordinary negligence, except for gross negligence or willful misconduct.
  • 8. Continuing Treatment: I will continue all prescribed medications and treatments as directed by my physician. Salt therapy is a complementary service only.
  • PHOTO/VIDEO CONSENT (Optional)*

  • SIGNATURE

  • I have read, understood, and agree to the terms above. I certify that all information provided is accurate and complete.
  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Mobile Saltworks | www.msaltworks.com | (919) 525-3210 | info@msaltworks.com
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