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Intake & Consent Forms

Above & Beyond Hair & Body Salt Room Intake & Consent Form

Name:___________________________________________ Date:________________________

Address:______________________________ City:___________ State:____ Zip Code:________

Primary Phone:______________________ Email:______________________________________

Birthdate:_____/_____/_______Reason for your visit today:______________________________


Skin Conditions_________________________________________________________________

Are there any medical conditions we should be aware of? ___________________________________

Have you had a fever in the last 24 hours? (circle) YES / NO How did you hear about us?_________

Have you tried Halotherapy before? (circle one) YES / NO If yes, where? ____________________

Emergency contact: ________________Relation: ____________ Phone number:_______________

Consent and Release for Halotherapy Treatment

I am aware that there is a video camera being monitored 24/7 within the cave to ensure the safety of all our guests.

A Relaxed You, Inc. is not responsible for any lost or stolen items. There will be no Cell Phones, food, drinks, or electronics permitted

inside the cave. I agree to stay seated once the session begins and I will not pick up salt or touch the walls. I understand that all articles

of clothing must be kept on throughout the session. Halotherapy is not intended to diagnose, treat, cure, or prevent diseases and

respiratory issues. I understand that this is not a replacement for medical treatment and I have received medical clearance from a

medical professional prior to engaging in halotherapy, if I had any prior concerns. I have been advised of the possible side effects:

dry/itchy throat, nasal drip, and mild coughing—all signs of the respiratory cleansing process at A Relaxed You, Inc.

By signing below, I give consent to participate in halotherapy sessions and certify that I have read and agree to the terms listed above.

Client/Legal Guardian Signature: ____________________________________ Date: __________________________

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