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DW Intake & Release of Liability

Destination Wellness

INTAKE FORM & RELEASE OF LIABILITY

Personal Information

Birthday
Month
Day
Year
Multi-line address

Emergency Contact

Health Information

Current Health Status
Good
Fair
Poor
Medical History (Check any that apply and provide details if necessary):
Allergies (Include Medication Allergies)
No known allergies
Yes*

Sauna Use

Previous experience with infrared saunas:
None
Some
Frequent
Primary reason for using the infrared sauna:
Frequency of intended sauna use:
One-time
Weekly
Monthly

CONSENT AND AGREEMENT

Acknowledgment of Risks and Waiver of Liability - DW

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Date and Time:
Month
Day
Year
Time
HoursMinutes

Acknowledgment Of Risks and Waiver of Liability - Infrared Sauna

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Date and Time:
Month
Day
Year
Time
HoursMinutes

Privacy Acknowledgement

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Date and Time:
Month
Day
Year
Time
HoursMinutes

PARENT OR GUARDIAN

ADDITIONAL AGREEMENT


(Must be completed for participants under the age of 18)

In consideration of minor being permitted to participate in this activity, I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.

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Date and Time:
Month
Day
Year
Time
HoursMinutes

Destination Wellness

31 W Church Street

Newark, OH 43055

(740) 280-2031

lcdestinationwellness@gmail.com

www.lcsdestinationwellness.com

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