CONSENT FORM

Please fill out the following form
in order to participate in your session.  This form is mandatory and required to be completed prior to any services being offered.

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?

FLOAT THERAPY CONSENT

We make all reasonable efforts to ensure a comfortable, clean, and safe environment for you. As such, you may be provided the opportunity of using our floatation tanks. Please read over the following information and sign your name and date at the bottom of the form to indicate your agreement and adherence with our policies and procedures.

1. I will NOT use the floatation tank:

• If I am on my menstrual cycle

• If I have just shaved (salt will aggravate the pores.)

• If I have oils, creams on my body. (see point 2 below to shower)

• If I have jewelry on my body. (jewelry and piercings must be removed)

• If I have any communicable or infectious disease or illness, skin disorder, large cuts, open sores or

wounds

• If I am under the influence of alcohol or drugs

• If I am epileptic, unless in my opinion of my physician, my epilepsy is under medical control so that I am in sufficient control of my seizures not to endanger myself in the flotation tank

• If I am pregnant and have NOT consulted and received permission to float from my heath-care

provider

• If I suffer or have suffered from any claustrophobic or small or enclosed space anxiety-provoking

disorders

• If I suffer from diabetes, unless, in the opinion of my physician, my diabetes is under medical control so that I am in sufficient safety to use the flotation tank

• If I suffer or have suffered from chronic heart disease, unless, in the opinion of my physician, my

chronic heart disease is under medical control so that I am in sufficient safety to use the floatation tank

2. 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 (up to a total of $500) It is up to each individual to take caution to prevent slipping or falling as the floor surfaces will be wet.

3. I understand that using any self-tanning products or hair coloring must be complete at least 48 hours prior to floating

4. 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

5. 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

6. Upon using this floatation room, I absolve TRI-CITIES TRANQUILITY, LLC, employees and agents from any and all liability in connection with the use thereof whether such loss or damage is direct or indirect

7. 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

 

TANNING/RED LIGHT THERAPY CONSENT

 

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 about tanning as possible. This means informing you how to operate the tanning equipment. The proper procedure to follow in the tanning room will be clearly explained by a member of our staff. Please feel free to ask any questions.

 

IF YOU DO NOT DEVELOP A TAN OUTDOORS, YOU ARE UNLIKELY TO TAN- FROM THE USE OF ANY TANNING DEVICE.

 

1. AVOID OVEREXPOSURE. As with natural sunlight, overexposure can cause eye and skin injury and

allergic reactions. Repeated Overexposure may cause photoaging of the skin, dryness, wrinkling and

in some instances skin cancer. We recommend that you do not tan outdoors on days you are tanning indoors, that you do not tan if you currently have a sunburn and that you, at most, tan only once in a 24 hour period.

2. CERTAIN MEDICATIONS, Lotions and other Products may cause your skin to be more sensitive to

UV Rays. Check the posted list of drugs and products known to increase the photosensitivity of the skin. Check with your physician or pharmacist if you are unsure about any medications you are taking or if you have had a problem with indoor or outdoor tanning in the past. 

3. WEAR PROTECTIVE EYEWEAR. Failure to wear protective eyewear may result in severe burns or

long-term injury to injuries to the eyes.

 

I have read the contents of this consent form carefully and state that I am not aware of any medical condition or other reason that would prohibit me from tanning. I understand that I will not be allowed to exceed the maximum allowable time posted on the tanning device. I have been given adequate instructions for the proper use of the tanning equipment, understand the risks involved, and use it at my own risk. I hereby agree to release the owners, operators and manufacturers from any damages that I might incur due to the use of this facility.

 

Signature: ___________________________Client # _____________ Date: _________________

Print Name Of Client:____________________________________________________________

Witness (Employee) Signature: _______________________________Date: ________________

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For illiterate or visually handicapped persons, this release form has been read to the user in

my presence. Witness: ____________________________________ Date: __________________

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I HEREBY GIVE MY PERMISSION as parent ( ) guardian ( )

of____________________________________________________ who is ______ years of age,

to tan or 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: _____________________________________________ Date: ___________________

Print Name of Parent/Guardian: ___________________________________________________

Thanks for submitting!