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First Name*

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Last Name*

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Email*

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Phone*

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Zip Code*

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Emergency Contact*

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Emergency Phone*

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Is this your first time floating?*

Yes No Invalid Input

The following listed conditions are considered contraindications for Float Tank Usage.
IF YOU ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS, YOU MUST GET A RELEASE FROM YOUR PHYSICIAN BEFORE USING OUR FACILITY. Please indicate if any of the following apply to you:

Do you suffer from Congestive Heart Failure?*

Yes No Invalid Input

Do you have a severe past or current neck injury?*

Yes No Invalid Input

Do you have Epilepsy, seizures, or blackouts?*

Yes No Invalid Input

Do you have Kidney disease?*

Yes No Invalid Input

Do you have uncontrolled Diabetes?*

Yes No Invalid Input

Do you have a condition which may be adversely affected by cutaneous absorption of Magnesium?*

Yes No Invalid Input

IF YOU ANSWER YES TO ANY OF THE QUESTIONS BELOW, PLEASE DO NOT USE FLOAT TANK UNTIL YOU REMEDY THE ISSUE.

Do you have lotions, oils, creams, or makeup on your body? (Please wash off in shower provided)*

Yes No Invalid Input

Do you have any voluntary/involuntary release of bodily fluids of any kind, including incontinence or a heavy menstrual period?*

Yes No Invalid Input

Do you have issues getting up from laying down on the floor?*

Yes No Invalid Input

Do you have a communicable or infectious disease, virus, or illness?*

Yes No Invalid Input

Do you have any open sores or recent flesh wounds?*

Yes No Invalid Input

Are you under the influence of alcohol or any drugs (prescription or otherwise)?*

Yes No Invalid Input

In the last week, have you dyed your hair, received Keratin treatments, or gotten a spray tan or tattoo?*

Yes No Invalid Input

I am aware that this facility uses an abnormal amount of water (H2O) and that wet conditions may result in bodily injury. I will exercise the highest level of caution when on premise, especially in the float tank rooms, in and around the float tanks, and showering areas.

I understand that the floatation pod 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. I also hereby agree and understand that I shall have consulted with my own health care provider prior to using the flotation pod if I am currently taking any medication or under a physician’s care for any reason. Upon using this flotation pod, I absolve Sapphire Springs Hydrotherapy center, and their employees and agents from any and all liability in connection with the use thereof whether such loss or damage be direct or indirect. I further agree to take full responsibility for my thoughts and actions while in the flotation pod and the waiver of liability and all agreements made herein shall apply to each use I make of the flotation pod. I will not touch or change any parts on, in or around the pod and will stay clear of the filtration system at all times. I will keep the room clear of any floods and will not change or re-arrange anything in the room and will leave everything in the order that I’ve received it in. NOTICE: A $500-$1500 cleaning / damage fee will be charged for any soiled flotation pod.

Please note that Sapphire Springs Float Spa reserves the right to charge $25.00 for appointments cancelled less then 24 hours. No call / no show will result in full charge and the loss of your appointment. All floats purchased are non-refundable.

I have read, understand, and agree to all of the terms listed above.

Are you signing on behalf of a minor?*

Yes No Invalid Input

If YES, enter the minor's name

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What is your relationship to the minor?

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If you are using a touch screen (phone, tablet, etc.), use you finger to sign your name in the box below.

Signature*

Sign Above

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