Rise And Be Well & Fractalize

Float Spa Informed Consent Floatation Therapy

*IMPORTANT INFO* PLEASE READ THIS ENTIRE DOCUMENT

At Rise And Be Well & Fractalize, and in other Float Spas around the world, the Floatation experience is not specifically intended to cure, treat, prevent or heal any disease, injury, or illness. I understand that if I have a health problem, or think I may have a health problem, I will be referred to a licensed professional for further assistance upon my request. 

FOR CLARITY NONE OF THIS HAS EVER HAPPENED

____ I hereby confirm that I am using the flotation facilities at my own risk. I further understand that while using the flotation facilities I could fall due to slippery surfaces resulting in severe injury, paralysis, brain damage or death.

____ I hereby confirm and understand that Flotation Therapy can cause intense relaxation and it could influence motor skills and the ability to drive heavy machinery. Upon exiting the Float Therapy Spa I take all responsibility for my actions.

____ I am not taking prescription medicine OR alternatively I have consulted my Doctor about Flotation Therapy and understand all associated risks in combination with my medication.

____ I do not have a pacemaker and do not have any serious heart disease OR alternatively I have consulted my Doctor and understand all associated risks of Flotation Therapy in combination with my specific medical conditions.

____ I do not suffer from epilepsy, psychotic attacks, respiratory, kidney or communicable disease. In rare cases Flotation causes nausea, vomiting, dizziness, and rashes. These could be a sign of a Kidney disorder and an inability to process magnesium. Should these symptoms occur please stop use of the Float Pod and consult your Doctor.

____ I am not under the influence of drugs, alcohol or illegal substances.

____ I have no history of ear infections and/or tubes in my ears OR alternatively I understand all risks associated with Flotation Therapy and my condition.

____ I understand that the Float Pod contains 10 inches of water and could cause drowning or injury.

____ I will pay a cleaning fee of $500 on the day of incident should I voluntarily or involuntarily have a bowel movement, urinate or discharge any other fluid in the Float Pod. (Women on their menstrual cycle must reschedule. There will be no penalty)

____ I have not dyed my hair within 2 weeks and understand that if I cause the water to change color because of hair dye, I will pay a $1000 cleaning fee.

____ I do not have any open wounds.

____ I understand that I need to use the float pod door handle ONLY to open and close the pod door, and if I do not follow these specific instructions, my safety may be at risk if the door (lid) malfunctions.

____ I understand that the metal bars that hold the pod door in place are not to be used to hang on or lift myself up, and if I do not follow these specific instructions, then my safety may be at risk if the door malfunctions due to the strain put on these bars.

Please also review our "First Time Floaters Checklist" on our website at least 24 hours prior to your appointment time to be sure that you are fully prepared to float on your scheduled time! This can be found at www.riseandbewell.com/first-time-floaters

I understand the above statements and it is my choice to participate in this experience. I further waive any and all liability of  Rise and Be Well & Fractalize for any injury that may occur. My signature below also stands as my initials for all the above statements.

SIGNATURE:______________________ NAME:____________________

EMAIL:____________________________________DATE:____________

PHONE NUMBER:____________________________