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Consultation Form Infrared Sauna
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Consultation Form Infrared Sauna
Infrared Sauna Consultation
First Name
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Last Name
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Date of Birth
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Address
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Contact Number
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Email
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Emergency Contact Name
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Emergency Contact Number
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Are you currently taking any medication?
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Yes
No
Please specify (Medication)
Do you have any medical conditions?
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Yes
No
Please specify (Conditions)
Are you currently, or possibly may be, pregnant?
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Yes
No
Do you have any allergies or intolerances?
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Yes
No
Please specify (Allergies/Intolerances)
I assume full responsibility for my medical/health conditions. I know my own limitations and assume all risks associated with any activities in which I may engage in the sauna therapy.
Cardiovascular Conditions, Medications, Chronic Conditions/Diseases Associated With Reduced Ability to Sweat or Perspire, Hemophiliacs/Individuals Prone to Bleeding, Fever, Insensitivity to Heat, Joint Injury, Implants: metal pins, rods, artificial joints, Pacemakers/Defibrillators, Pregnancy/Breastfeeding; If any of these conditions apply to me, I agree to consult a physician prior to participating sauna therapy.
I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given.
I consent to release and indemnify staff and any and all liability in connection with the use of the sauna, whether such loss or damage be direct or indirect.
I understand that eyeglasses should not be used in the hot room as they can become damaged in the heat. I understand that contact lens wearers may experience discomfort and should be prepared to remove contacts if this is the case.
I certify that I have read and fully understood and completed this form to the best of my knowledge.
I fully understand the above and consent to receive a wellness session.
I have read and agree to the consent above
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I agree
I agree to receive product information and promotions
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No
Signature
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Date
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