DEDARI WELLNESS

SAUNA & ICE BATH – HEALTH SCREENING & CONSENT FORM

Please complete this form honestly before participating in the wellness experience

22 questions ± 1 min

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Guest Name

Room Number

WELLNESS EXPERIENCE

Sauna Only Sauna + Ice Bath Hot & Cold Ritual

Please tick the experience you will participate in:

A. GENERAL HEALTH SCREENING – SAUNA & HEAT EXPOSURE

Please tick YES or NO. If you answer YES to any question, inform our Wellness Staff before proceeding.

Are you currently pregnant or possibly pregnant?

Yes No

Do you have any known heart or cardiovascular condition?

Yes No

Do you have high blood pressure that is not controlled or treated?

Yes No

Are you currently experiencing fever, flu, infection, dizziness, or feeling unwell?

Yes No

Have you ever fainted, felt dizzy, or experienced unusual symptoms during heat exposure?

Yes No

Are you currently under medical treatment or taking medication for a condition that may be affected by sauna or heat exposure?

Yes No

Do you have any other medical condition that may make sauna or heat exposure unsafe?

Yes No

B. ADDITIONAL ICE BATH SCREENING – ONLY IF PARTICIPATING

If you selected Sauna + Ice Bath or Hot & Cold Ritual above, please complete this section.

Do you have Raynaud's disease/syndrome or a condition causing an abnormal reaction to cold?

Yes No

Have you ever experienced unusual symptoms, fainting, or severe discomfort when exposed to cold?

Yes No

Do you have any medical condition that may make cold-water immersion unsafe?

Yes No

C. BEFORE YOUR SESSION

D. GUEST CONSENT

I confirm that the information provided above is true and complete to the best of my knowledge. I understand that sauna and ice bath involve exposure to heat and/or cold and may cause physical stress. I understand that Dedari Wellness is not providing medical treatment or medical advice. Participation is voluntary, and I may stop the activity at any time if I feel uncomfortable or unwell.

Guest Signature

Draw your signature in the white area

E. FOR DEDARI WELLNESS STAFF ONLY

Health screening reviewed by

Assessment

CLEARED CLEARED WITH PRECAUTION MEDICAL CLEARANCE REQUIRED NOT CLEARED

Staff Signature

Draw your signature in the white area

SAUNA & ICE BATH – HEALTH SCREENING & CONSENT FORM

A. GENERAL HEALTH SCREENING – SAUNA & HEAT EXPOSURE

B. ADDITIONAL ICE BATH SCREENING – ONLY IF PARTICIPATING

C. BEFORE YOUR SESSION

D. GUEST CONSENT

E. FOR DEDARI WELLNESS STAFF ONLY

Sent