Sauna Consent Form First Name*Last Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Date of Birth* Date Format: DD slash MM slash YYYY Please Answer the following questionsAre you pregnant?*YesNoIf you answered YES above, how far along?Are you taking any medications?*YesNoHave you been diagnosed with any medical condition, such anhidrosis, that may limit or prevent your ability to sweat?*YesNoDo you have unstable angina?*YesNoHave you had a recent heart attack?*YesNoDo you have a severe arterial disease?*YesNoHave you been diagnosed with any other medical condition?*YesNoIf YES, which condition?If you answered “yes” to any of the above questions, have you consulted with Your medical provider about using a near infrared sauna?*YesNo It is always important to maintain proper hydration levels during near infrared therapy. Dehydration will actually increase carbohydrate utilization and cause less fat to be burned for energy. We highly recommend drinking a minimum of 4 oz. of water prior to entering the sauna and a minimum of 8 oz. of water after sauna use. NEAR INFRARED SAUNA AGREEMENT/ACKNOWLEDGEMENT 1) The use of drugs, medication or alcohol prior to or during sauna sessions may lead to dizziness or unconsciousness. Clients using any medications must consult a physician or pharmacist prior to use of the sauna. 2) Please consult your physician if you are in doubt regarding your ability to use the near infrared sauna for health reasons. 3) No one under age of 18 is permitted in the near infrared sauna unless accompanied by a supervising adult. 4) Discontinue the use of the sauna if you feel light-headed, dizzy or heat exhausted. 5) Sauna sessions should be limited to no more than 20 minutes and temperatures must stay below 150 degrees Fahrenheit. 6) Clients using any medications must consult a physician or pharmacist prior to use of the sauna. 7) Pregnant women should consult their physician prior to use of the sauna. Excessive body temperatures have a potential for causing fetal damage during the early days of pregnancy. 8) The use of any electronic device in the sauna is at your own risk. Shelley Gawith Functional Nutrition is not liable for any damage do to heat exposure. SCHEDULING AND FEES We understand that our clients have busy schedules and we take pride in not keeping you waiting and not keeping you longer than planned. Payment is due at time of appointment. EFTPOS facilities are available. If you need to cancel or reschedule your appointment please do so 24 hrs in advance otherwise you will have to pay the full amount of your appointment. Consent* I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the use of near infrared sauna. I and any of my heirs, executers, representatives, or assigns hereby release all claims or liabilities for personal injury or property damages of any kind sustained while on the premises, during the use of the near infrared sauna and from any advice provided by an employee, independent contractor; or any representative. I agree that this Application and Waiver is in effect for all near infrared sauna sessions and will not expire unless specifically requested by either party.*CAPTCHA Δ
