Float Client Form

Please fill out the form below:

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

What do you hope to get out of your floating experience and fo you have a specific focus we may be able to assist you with? i.e pain management, relaxation etc. *

Do you have any health conditions and, if so, how are you managing them? (Chiropractic, physiotherapy, psychiartrist etc.) *

Do you have any allergies or sensitvities to the following? *

Chlorine Bromine Essential Oils

Are you currently pregnant? *

Yes No

Are you a member of any health/sport/fitness clubs? If so, please specify *

Date of Birth *

Phone Number *

Email *

Occupation *

Have you floated in a floatation tank before? *

Yes No

If yes, please indicate where you have floated and how much experience you have had: *

Are you taking any medication, and if so, have you experienced any side effects? *

Do you suffer from any symptoms of stress and tell us where you 'carry' your tension in your body. Do you have pain anywhere in your body from injury or strain? *

So you suffer from ear infections / grommets? *

Yes No

Do you play sport or are you involved in any other physical activity? If so, what? *

How did you hear about us? *

If 'other', please specify *

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Float Client Form

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