Float Pool Intake Form

Name

Date

Phone Number

Email Address

example@example.com

At Healing Elements Day Spa we have made all reasonable efforts to ensure a comfortable, clean and safe environment for your floatation experience. To ensure you have a safe and comfortable floating experience, please read the following guidelines, initial and sign your name where specified. This consent form applies now to your first float and all floats after this one. You will need to arrive 30 minutes before your appointment time.

The following list is to ensure your safety in your floatation service. Please initial each item to verify that you understand the guidelines:

1. I will shower washing my hair with shampoo only and not enter the float pod with any oils or creams on my body.

2. LADIES: I am not currently menstruating, if I am I will reschedule.

3. I do not have any open wounds or sores anywhere on my body.

4. I do not have any communicable/contagious diseases.

5. I am not under the influence of drugs and/or alcohol.

6. I am not epileptic, or I have discussed this with my physician that my epilepsy is under medical control and I am in sufficient control of my seizures to not endanger my floating experience.

7. I am not pregnant, or I have consulted and received permission from my physician.

8. I do not suffer from diabetes, or I have discussed this with my physician and he/she is of the opinion that my diabetes is under medical control and that I am in sufficient control to use the flotation pool.

9. I do not suffer nor have I ever suffered from chronic heart disease, or I this with my physician and he/she is of the opinion that my chronic disease medical control so that I am sufficiently safe to use the flotation pool.

10.I do not suffer nor do I possess any sort of existing ear, nose, or eye condition that may be irritated by properties within the float pool

11. I have not shaved or waxed 48 hours before my floating experience.

12. I have not had my hair chemically processed or received a spray tan within the last 5-10 days.

Before using the float tank you will need to use the shower in the locker room to rinse off any excess dirt, oil or cream on your body. Clients that have longer hair are recommended to tie their hair up for maximum floating comfort. In the even that I experience a medical emergency, I will contact a Healing Elements Employee to call 911 and will not hold them responsible for any costs or suffering as a result of my medical intervention I received. I acknowledge that if I contaminate the floatation pool in any way I will be required to pay the cost of clean up and refilling the pool ($500.00-$1,000.00 I understand that the flotation pool uses Epsom salt, natural enzymes, botanical extracts and non-toxic biodegradable cleaning products which will be in the water and that some people may experience skin allergies or reactions.

The flotation pool is used for relaxation purposes and needs to remain a quiet, tranquil environment. Please make every effort to be respectful and not disturb other clients while floating. Splashing kicking, talking or other disruptive behavior is not allowed. Children are not allowed in the floatation room while client is getting their service.

Signature

Date