Combo Form | Sun Moon Healing

Day at the Beach Combo Form

**NOTE:: If you have a pacemaker, heart conditions, are pregnant, prone to or previous stroke/TIA, blood clots or thrombosis, dizziness/vertigo or under the age of 16 - NO USE OF SAUNA IS ALLOWED**

We encourage you to try the Solar Halotherapy Salt Suite instead.

First name

Last name

Phone

Address

Birthday

Month

Day

Year

Gender

Male

Female

Prefer not to say

List medical conditions, current medications & the condition they are treating:

We encourage you to try the Solar Halotherapy Salt Suite instead.

Please tell us about any allergies or hyper-sensitivities:

Emergency Contact & Phone Number

I agree I DO NOT have a pacemaker, heart conditions, pregnant, prone to or previous stroke/TIA, blood clots or thrombosis, dizziness/vertigo or under the age of 16.

NO USE OF SAUNA IS ALLOWED for these conditions!

I understand and agree that the Solar Halotherapy Salt Suite is a DRY environment. Only personal water bottles are permitted, and I will ensure I am dry (or mostly dry if coming from the contrast therapy suite). No liquids, wet clothing, or damp items are allowed inside the Solar Halotherapy Salt Suite.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment.

Sioux's Wellness Essentials

Day at the Beach Combo Form

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