Salt Cave Medical Release

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Are you a Member?

Not yet

Yes, Individual Membership

Yes, Double Membership

Is this visit for you, someone else, or both?

For you

For someone else (a minor)

For both of you

If your child, Please state Name and Birthdate.

Anything Else

2. How long have you been experiencing the symptoms endorsed above?

3. What other remedies or medications you’ve tried?

4. Why are you interested in trying salt therapy specifically?

Date

Month

Day

Year

Signature

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