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Disclosure / Waiver / Release / Contraindications

I have requested and agreed to undergo the process of Salt therapy.  I have been informed about the potential benefits, risks and consequences of Salt therapy.  All my questions pertaining to Salt therapy have been answered to my satisfaction.  I am satisfied with and understand the information provided as well as I acknowledge that THE SALT ROOM recommends that all medical conditions should be treated by a physician competent in treating that condition.  I further acknowledge that THE SALT ROOM takes no responsibility for clients choosing to treat themselves by means of Salt therapy, which has not been evaluated by the Food and Drug Administration and is not intended to diagnose, treat, cure or prevent any disease.  I understand that for all my health concerns, it is my responsibility to consult an appropriately licensed healthcare practitioner.  I further release THE SALT ROOM at SVB from any legal ramifications should an injury, death, or illness occur as a result of Salt therapy. 

Drug interactions – None

Salt therapy is a non-invasive, 100% drug-free, chemical-free, all natural solution. The benefits of salt therapy are many, and safe for all ages. 

The following are the primary contraindications:

  • Acute stage of respiratory diseases
  • Chronic obstructive lung diseases with the 3rd stage of chronic lung insufficiency
  • Intoxication
  • Cardiac insufficiency
  • Bleeding
  • Spitting of blood
  • Hypertension in IIB stage

I hereby give my consent to participate in the Salt Therapy Sessions entirely at my own risk for myself and listed children.

Salt Etiquette:

  1. Please refrain from wearing perfumes or other fragrance producing products.
     
  2. Arrive early sessions must start as scheduled to allow time for sanitizing & cleaning.
     
  3. Please leave your purse, keys, phones and other valuables in designated area.
     
  4. We recommend electronic devices be put in a plastic bag. Headphones must be used.
     
  5. No food or drinks are allowed in the salt therapy room.
     
  6. Use the rest room before the session starts.
     
  7. Please wash your hands before each salt therapy session.
     
  8. Disposable foot covers must be worn over shoes in the salt therapy room.
     
  9. While in progress, no one is allowed to enter the salt therapy room.
     
  10. Please do not exit the salt room once a session has begun, except for an emergency.
     
  11. Due to the delicate nature, we ask that you Do Not touch the salt wall.
     
  12. Please help us maintain a quiet healing environment by keeping the noise down.
     
  13. Presence of a guardian is required for children under 12 years of age.
     
  14. Children 6 & under must be accompanied by an adult in the therapy room.
     
  15. If you use an inhaler, please be sure to bring it with you.
     
  16. Drink plenty of water following your salt therapy.
     
  17. Cancellation policy: Your appointment time has been reserved especially for you. On occasion you may need to change your appointment. We kindly ask that you give us a 24 hour notice when cancelling or rescheduling your appointment.

I have read, understand, and will comply with the “Salt Room Etiquette” provided to me.

Dated: October 27, 2021

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's 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*
Check to receive information, news, and discounts by e-mail.
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 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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