CLOUD NINE FLOTATION SAFETY COMPLIANCE and LIABILITY WAIVER AGREEMENT

CLOUD NINE FLOTATION SAFETY COMPLIANCE and LIABILITY WAIVER AGREEMENT

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We make every reasonable effort to provide and ensure a comfortable, clean and safe floating environment for you and ask that you comply with all of our directives and procedures. Please read and initial or check each of the follow statements of this agreement and sign below.

I do not have any communicable or infectious disease, illness, open sores, or skin disorders.

I do not have freshly dyed (colored) hair (when I shower the water runs clear).

I am not menstruating.

I am not under the influence of non-prescribed drugs or alcohol or non-prescribed medication.

I do not have a condition where I am receiving medication that may be adversely affected by deep relaxation and/or immersion in Epson salt solution.

I do not have untreated high (>+180/120) or low (<-90/50) blood pressure.

I am not diabetic with insulin dependency, or I have medical authorization to float.

I do not have chronic heart or kidney disease. If I do, I have medical authorization to float.

I do not suffer from seizures or epilepsy. If I do, I have medical authorization to float.

I do not have claustrophobia. If I do, I have medical authorization to float. (Ask about Special Protocols).

I am at least 18 years of age or have guardian with me to sign waiver.

I have secured written permission to float from my physician if I am pregnant.

What interests you most about floating? What would you like to experience from it?:

What areas of your life do you hope floating will help improve?  Check as many as needed

PHYSICAL GOALS:
Increased EnergyAlleviate Physical PainAthletic EnhancementRapid Physical RecoveryHeadache ReliefLower Blood PressureImprove Sleep QualitySpeed Jet-Lag Recovery

MENTAL GOALS:
Increase MotivationImprove ConcentrationImprove Problem-SolvingIncrease CreativityIncrease IntuitionMeditation PracticePersonal GrowthElevate Mood

CLINICAL GOALS:

Stress ReliefReduce Stress-Related IllnessDepression ReliefAnxiety ReliefPTSD SymptomFibromyalgia ReliefEliminate Addictive BehaviorsEating Disorder

Any additional therapy goals not listed above:

If experiencing physical pain, where is this pain:

On a scale of 1-10, 1 being no pain, and 10 being crazy horrible pain, where are you today?
12345678910

What do you currently do to alleviate the above concerns?

Please list any additional medical conditions:

Cloud Nine uses:
35% hydrogen peroxide (H202)
Ultraviolet (UV) sterilization systems and Ozone
Natural enzymes, botanical extracts and non-toxic biodegradable cleaning products.

I am not allergic or skin-sensitive to these products used as a sanitizing agent.

I will not float with oils or creams on my body, hair products, jewelry, clothes or contact lenses.

I feel well today, have no incontinence or nausea, and will only float when I feel well.

I have or will receive(d) an orientation, which familiarizes me with the safe and appropriate use of the tank. I understand that individual experiences with floating are varied and unique, and I take full responsibility for my thoughts and actions while in the flotation tank. This waiver of liability and all agreements made herein shall apply to each and every use of the tank.

I hereby agree to irrevocably hold harmless and waive any claims that I now may have or may have hereafter against Kalyn Wolf Consulting LLC DBA Cloud Nine Flotation, its owner, employees, agents and dependents.

I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability in connection with the use of the flotation tank and facilities, including the entire interior of the premises operated as Cloud Nine Flotation, its agents and all employees, whether such loss or damage be it direct or indirect.

I understand that if I do something that causes damage to the Cloud Nine Flotation Tank, or its contents, I am financially responsible.

Any actions by the client, that requires Cloud Nine Flotation to replace the sensory deprivation tank solution will require a $1,500 replacement fee to be paid by the client.

I agree to the Cloud Nine Flotation Return, Cancellation and No Show Policies on the website and on paper.

If you are over 18 please sign below. If under 18 your parent or guardian must sign for you.

Type in Name for Digital Signature:

Current Date: