Confidential Consent Form Float In Vermont Liability Waiver & Professional AgreementToday’s Date:(Required) MM slash DD slash YYYY First Name:(Required) Last Name:(Required) Street Address:(Required) City:(Required) State:(Required) Zip:(Required) Date of Birth:(Required) MM slash DD slash YYYY Email:(Required) Cell Phone:How would you like to be reminded of upcoming appointments? Email Phone Text Emergency Contact: Phone:We want you to have an enjoyable and safe experience with us at Float in Vermont. We ask that you be aware of and agree to the following information and policies:Facilities Amenities provided include: towel, washcloth, ear plugs, shampoo/body wash, and shower. It is up to each individual to take caution to prevent slipping or falling as floor surfaces may be wet. The facility is cleaned between each session and the float pool solution is sanitized to meet or exceed the standards of the Floatation Tank Association. Our filtration process begins when guests leave their float room. The water is sanitized through 4 cycles of treatment between each float session in accordance with Health Authorities: 1. Primary particle filter 2. Ozone 3. UV filtration 4. 1-micron filter plus a ¼ teaspoon of bromine granules are added between floaters at the time of filtration.Our staff is not trained in assisted transfers and our float tank is not ADA compatible. If you need assistance you must bring your own helper.Are you able to safely get yourself in and out of the float pool? Yes No Please list any medical conditions that may be of concern to your safe enjoyment of our facility:Fees Fees vary based on the desired service package. These fees are subject to change. We require payment for services at the time of service.Cancellation Policy If a cancellation is necessary we require at least 24 hours notice before your scheduled appointment. Failure to give this notice, or no shows, will result in a 100% of the normal session fee charge. If you have purchased a prepaid package, one session will be deducted for no shows or failure to provide 24 hours notice of cancellation from your package. Thank you for your understanding.Please initial here to accept our cancellation policy:(Required) I, the willing customer, will NOT use the float pool if: ● I have not showered thoroughly and still have oils, creams, or makeup on my body.* ● I have had any type of hair color/treatment within the past two weeks.* ● I am under the influence of alcohol or drugs. ● I have a communicable or infectious skin condition, disorder, or diseases. ● I have open sores. ● I am diabetic, unless my diabetes is under medical control. ● I have a history of heart trouble, epilepsy, seizures or blackouts and have not received my doctor’s permission to use the floatation tank. ● I am experiencing a heavy menstrual period and menstrual blood could come out into the water.* ● I have a condition which may be adversely affected by cutaneous absorption of magnesium. ● I have kidney disease. ● I may release bodily fluids, voluntarily or involuntarily, into the float pool.* I understand that violation of any of these above rules that results in contamination of the float pool water may result in a cleaning and salt replacement fee of up to $1,000. I am choosing to use the floatation therapy pool of my own free will and will not hold the owner/operator, Float In Vermont or Integrative Acupuncture LLC liable for any injury during a session or while on the premises. Float in Vermont reserves the right to refuse service to anyone. I consent to the Infrared Sauna Treatment. I understand that these procedures are not intended to take the place of medical care or medications. I am waiving liability to Integrative Acupuncture, dba Float In Vermont, and I am entering the sauna at my own risk. I understand I can discontinue my sauna use at any time. I will step out of the infrared sauna immediately if I experience dizziness or if I am sleepy. In the rare event that I experience pain and/or discomfort, I will immediately discontinue sauna use. I have read, understand and agree to all of the terms & policies listed above. This signed document represents an agreement between us.Signature:(Required)Date:(Required) MM slash DD slash YYYY Signature of Parent or Legal Guardian, if client is under 18: CommentsThis field is for validation purposes and should be left unchanged.
