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Dry Salt Therapy: Assumption of Risk, Waiver And Release From Liability

Salt Therapy is 100% natural, safe, and drug free, providing effective long-term relief. It can be used as a complimentary treatment to prescribed medications or as a sole treatment. When Salt therapy is used as a complementary treatment, it can increase the effectiveness of prescribed medications and decrease the amount prescribed.

Although published studies do indicate that Salt therapy appears to have health benefits as an addition to more traditional forms of medicine, Salt Wellness Centre (Salt) does not claim to be a replacement for medication or any medical treatment of any kind. Only your personal physician or other health professional can best advise you on matters of your health. The research supporting the use of Salt therapy was undertaken outside of Canada and haven’t been filed with Health Canada for approval.

Salt therapy should be avoided during the acute phase of any illness, including the following infections accompanied by fever, acute active tuberculosis, cardiac insufficiency, COPD in the third stage, bleeding, spitting of blood, contagious ailments, have use of an oxygen tank to aid breathing, alcohol or drug intoxication, unstable or uncontrolled hypertension and acute stages of respiratory diseases.

I, a client of Salt Wellness Centre (Salt) hereby release Salt Wellness Centre (Salt) and its directors, officers, employees, agents and professional staff from all actions, causes of action, suits, claims of liability, damages and demands of any kind, whether direct, indirect, special, exemplary or consequential, including interest thereon (the Claims) which may occur as a result of injury including death sustained by myself or others resulting from the receipt of Salt therapy.

 

During the Salt therapy session, Salt Wellness Centre (Salt), is using pure and untreated 99.9% (USP grade) sodium chloride only. I fully understand the above disclaimer and use Salt therapy at my own risk.

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Second Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Third Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fourth Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Fifth Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Sixth Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Seventh Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Eighth Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Ninth Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Tenth Client Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
Client 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*

Confirm Email*
We send payment receipts by email to help minimize our footprint, save trees and stay green. By giving us your email address you are providing us with permission to contact you via email. We will never share your email address and you can breakup with us (or unsubscribe) at any time. We’ll only email you about specials, fun events, and the occasional super entertaining newsletter
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*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you tried Dry Salt Therapy before?*
No
Yes
How did you hear about Salt Wellness Centre? *
Facebook
Instagram
Online Search/ Internet
Other Social media
Other
Referral
Walked by
Why are you seeking Salt Therapy? (Check all that apply.) *
Allergies
Asthma
Athletic Performance
Cold/ Flu
COPD
Eczema
General Wellbeing
Other
Psoriasis
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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