Float Therapy Consent Form
Please complete this form before your float therapy session. Your information helps us provide a safe and relaxing experience.
Participant Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Session Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Have you used float therapy before?
*
Yes
No
Health Screening: Please indicate if you have any of the following conditions.
*
Open wounds or skin infections
Epilepsy or seizure disorders
Severe low blood pressure
Recent surgery (within 6 months)
Allergy to Epsom salts
None of the above
Please list any other medical conditions or medications we should be aware of.
Float Preferences: Would you like music during your session?
*
Yes, music throughout
Music only at the beginning/end
No music
Float Preferences: Preferred lighting
*
Dim lighting
No lighting (complete darkness)
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Consent
Should be Empty: