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We make all reasonable efforts to ensure a comfortable, clean, and safe environment for you.  Please read over the following information and sign at the bottom of the form to indicate your agreement and adherence with our policies and procedures.

Release of Liability and Waiver

  • I will NOT use the Float Pods with oils, lotions, creams, or jewelry on my body; nor have I colored my hair in the last 7 days.
  • I will NOT use the Float Pods if I have any communicable or infectious disease or illness, skin disorder, large cuts, open sores or wounds.
  • I will NOT use the Float Pods if I am under the influence of alcohol or drugs.
  • I will NOT use the Float Pods if I am taking powerful sedatives or have schizophrenia.
  • I will NOT use the Float Pods if I am epileptic, unless in the opinion of my physician, my epilepsy is under medical control so that I’m in sufficient control of my seizures not to endanger myself in the floatation tank.
  • I will NOT use the Float Pods if I am being treated with chemotherapy.  
  • I will NOT use the Float Pods if I suffer from diabetes, kidney failure, or chronic heart disease unless, in the opinion of my physician, these conditions are under medical control so that I am in sufficient safety to use the floatation tank.
  • I further understand that the floatation tanks use (1) Epsom Salt, (2) Chlorine, and (3) natural enzymes and 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 physician prior to using the floatation tank if I am currently taking any medication or under a physician’s care for any reason.
  • I hereby agree that if I voluntarily or involuntarily defecate, urinate or discharge any other bodily fluid in the Float Pod that I will be required to pay the cost of cleanup and refilling the pod with salt.  ($1000 cost)
  • Upon using the floatation tank, I absolve Still Life Massage and Float, PS and its employees and agents from any and all liability in connection with use thereof whether such loss or damage be direct or indirect.  I further agree to take full responsibility for my thoughts and actions while floating.  The waiver of liability and all agreements made herein shall apply to each use of the floatation tank.

Date: September 20, 2018

First Float Clients Name

First Name*

Last Name*

Phone*
First Float Clients Date of Birth*
First Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
First Float Clients Signature*
Second Float Clients Name

First Name*

Last Name*
Second Float Clients Date of Birth*
Second Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Third Float Clients Name

First Name*

Last Name*
Third Float Clients Date of Birth*
Third Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Fourth Float Clients Name

First Name*

Last Name*
Fourth Float Clients Date of Birth*
Fourth Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Fifth Float Clients Name

First Name*

Last Name*
Fifth Float Clients Date of Birth*
Fifth Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Sixth Float Clients Name

First Name*

Last Name*
Sixth Float Clients Date of Birth*
Sixth Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Seventh Float Clients Name

First Name*

Last Name*
Seventh Float Clients Date of Birth*
Seventh Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Eighth Float Clients Name

First Name*

Last Name*
Eighth Float Clients Date of Birth*
Eighth Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Ninth Float Clients Name

First Name*

Last Name*
Ninth Float Clients Date of Birth*
Ninth Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Tenth Float Clients Name

First Name*

Last Name*
Tenth Float Clients Date of Birth*
Tenth Float Clients Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Float Clients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Would you like us to email you our offers/specials?
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
How did you hear about us?*
Have you Floated before?*

What is your main reason(s) for Floating?

Is there anything else you would like to share with us?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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