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Infrared Sauna Release Form 

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, sauna use may be contraindicated. A referral from your primary care provider may be required prior to service being provided.

Have you ever used an infrared sauna before?     Yes     No 

Please mark any of the following questions to indicate a “yes” answer:

Do you have a heart pacemaker or any other battery operated or electrical impant? ________________

Are you pregnant or breastfeeding?_____________________

Do you currently have a fever, infection or injury? _______________________

Do you have uncontrolled high blood pressure, or experienced a heart attack or other cardio- vascular problem? _______________________________

Do you have a history of dizziness, fainting spells, heat sensitivity, narcolepsy or seizures? _____________

Do you suffer from any bleeding disorders? _______________________________

If you answered ‘yes’ to any of these questions it is not recommended that you use the infrared sauna at this time. We suggest that you consult your Primary Health Care Physician to obtain a release form before proceding with infrared sauna therapy. 

Please Note 

Sauna sessions should be limited to no more than 60 minutes. 

Drink plenty of water before, during and after your session. 

If you experience pain and/or discomfort, immediately discontinue and exit the sauna. 

If you are on any medications, consult with your doctor before using the infrared sauna. 

Do not use drugs, tobacco, or alcohol prior to or during the sauna session. 

No one under the age of 18 is permitted in the far infrared sauna. 

If you have a medical condition or are on any prescription medications, consult with your physician before using the infrared sauna. 

Discontinue the use of the sauna if you feel light- headed, dizzy, heat exhausted, or unwell. 

AGREEMENT

I acknowledge and accept the risks inherent in the use of an Infrared sauna. I voluntarily assume the risk of injury, accident or death, which may arise from the use or improper use of the infrared sauna. I and any of my heirs, executors, representatives or assigns hereby release from all claims or liabilities for personal harm or  injury or property damages of any kind sustained while on the premises, during the use of the infrared sauna and from any advice provided by an employee or any representative. I agree that this release is in effect for all infrared sauna sessions. 

None of the information provided is intended to act as a substitute for medical advice, nor does it involve the diagnosis, prognosis, or prescription of remedies for the treatment or prevention of any disease or ailment. I certify that everything on this form is true and correct to the best of my knowledge. I also understand that the infrared sauna alone is not intended to diagnose, treat, cure, or prevent any disease or ailment. 

LATE CANCELLATION OR NO SHOW POLICY: I (the undersigned) agree to pay Royal Yoga Studio  $25 if I fail to cancel my appointment 12 hours in advance, or if I miss my scheduled appointment entirely. 

I agree to limit all Sauna Sessions to 30 minutes or less at a temperature not to exceed 140 degrees F. 




117 W. Adrian St, Blissfield, MI  *  517-605-6616 *  www.royalyogablissfield.com  *  Jessica.royalyoga@gmail.com

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*
Parent or Guardian's Email Address

Email*

Confirm Email*
Health Questions & History
Have you ever used an infrared sauna before?*
No
Yes
Do you have a heart pacemaker or any other battery operated or electrical impant? *
No
Yes
Are you pregnant or breastfeeding?*
No
Yes
Do you currently have a fever, infection or injury? *
No
Yes
Do you have uncontrolled high blood pressure, or experienced a heart attack or other cardio- vascular problem?*
No
Yes
Do you suffer from any bleeding disorders? *
No
Yes
Do you have a history of dizziness, fainting spells, heat sensitivity, narcolepsy or seizures? *
No
Yes

If you answered ‘yes’ to any of these questions it is not recommended that you use the infrared sauna at this time. We suggest that you consult your Primary Health Care Physician to obtain a release form before proceding with infrared sauna therapy.
Emergency Contact

First Name*

Last 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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also 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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