Salt Water Floatation Intake Form

We take your privacy very seriously.
Your personal information will never be shared with any outside party.

Your Contact Information
*First Name
*Last Name
*Email
*Address Street 1
*Address Street 2
*Address City
*Address State
*Address Postal Code
*Address Country
*Mobile Phone	( ) -
*Home Phone	( ) -

Your Emergency Contact
*Emergency Contact Name
*Emergency Contact Phone	( ) -

General Information
*Birthday
*What gender do you identify with?
*Occupation

How did you hear about us? (check all that apply)*
Internet Search	Billboard	A Look At Asheville (hotel book)
Trip Advisor	Rack Card/Flyer	Mountain Xpress (newspaper)
Facebook	LEAF (festival)	Received a Gift Certificate
Yelp	Asheville Community Yoga	Map of Asheville
Referred by Friend/Word of Mouth - (Who referred you?)
Other (please list):

What are your goals and intentions? (check all that apply)*
Pain Relief	Boost Immune Function	Overcome Addiction	Enhance Creativity
Relaxation	Expand Consciousness	Overcome Anxiety	Enhance Quality of Life
Sleep Better	Inner Exploration	Overcome Depression	Enhance Sports Performance
Therapeutic	Mental Focus/Meditation	Overcome Insomnia	Enhance Work Performance
Curiosity	Mind/Body Awareness	Overcome Phobias
Other (please list):

*What tools, practices and activities do you use to relieve stress and maintain your wellbeing?

*Have you ever used a floatation tank?

Yes

*Where in your body do you hold tension?

Health Questionairre
The following questions help us to address concerns and assess if you have any conditions that might be contraindicative to floating. Please check all that apply and explain if necessary.

Do you have any of the following conditions? If so, please refer to our Contraindications page.*
Eczema	Low Blood Pressure	Open Scrapes, Cuts or Wounds
Epilepsy	Kidney Infection	Contagious Disease
Incontinence	Respiratory Infection	Contagious Skin Condition
None

*Are you pregnant?

Yes No

*When is your due date? (MM, YYYY)

*Do you wear contact lenses?

Yes No

*Are you currently experiencing any of the following?
Mild Claustrophobia	Anxiety	Fear of Dark	Obsessive/Compulsive Tendencies
Intense Claustrophobia	Depression	Panic Attacks
None

*Other health concerns mental/medical conditions and/or phobias

Release of Liability

I agree to check myself, care for myself and be fully responsible for myself as I use the floatation chamber, shower and room and as I travel in and move upon the surfaces of both my mind, my physical, and my emotional environments. I have made no misrepresentations to Still Point Wellness, any of its agents or employees regarding my physical or mental conditions. I accept and expressly assume for my use the isolation tank, shower and room facilities and accept full responsibility for the use, and while I am in possession, the control of all of this equiptment. I hereby agree and accept the terms and conditions for this contract and acknowledge that Still Point Wellness has provided no warranties, expressed, oral,or implied, about my expectations being met or anticipated, or unforeseeable experiences. I understand that I will be shown how the floatation tank, shower, and all the room systems work and that I will be instructed in the proper use. I understand that floating, showering, being in control and care of myself, my room and its environment is my own controlled activity and that the floatation, showering, movements and isolation experiences involve a risk of possible injury to me and I hereby agree to freely and expressly assume and accept any and all risks of injury and release Still Point Wellness from liability should injury occur.

Still Point Wellness does not condone the use of drugs and/or alcohol while using the salt water floatation chamber. I agree to abstain from using drugs and/or alcohol while I am in the floatation chamber.

I agree to give 48-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 48-hour notice or do not show up to my appointment I agree to pay the full cost of the salt water floatation experience.

By submitting this form I affirm the accuracy of the information I have provided and understand and agree to the policies above.

* I agree