191 N. El Camino Real #210 / Encinitas, CA 92024 / p: 760-566-5832 / www.chiltonic.com
Physical Readiness Questionnaire
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EXCESS LOTIONS, SWEAT, OILS, BALMS, MENTHOL RUBS OR OTHER MOISTURE MUST BE REMOVED PRIOR TO TREATMENT.
ALL JEWLERY FROM THE NECK DOWN MUST BE REMOVED PRIOR TO TREATMENT.
WAIVER AND RELEASE AGREEMENT PLEASE READ CAREFULLY BEFORE SIGNING
This is a release of liability and a waiver of certain legal rights.
Participation in a Cryotherapy session involves exposure to extreme cold temperatures for a short period of time (not to exceed three (3) minutes per session). Below is a list of Absolute Contraindications which will preclude you from participation. In addition, PLEASE BE AWARE, that if you experience any pain or mental or physical discomfort at any time during the process, you are advised to terminate the session immediately upon your own volition. You will be observed by a technician the entire time while in the chamber, but are free to stop the treatment and exit the chamber at any time.
(Participation in cold therapy is NOT allowed)
• Untreated Hypertension
• Heart attack within previous 6 months
• Unstable Angina Pectoris
• Peripheral Arterial Occlusive Disease
• Ischemic heart disease
• Severe Anemia
• Raynaud's disease
• Seizure disorders
• Hyperhidrosis - heavy perspiration
• Alcohol and drugs relative contraindications
• Decompensating diseases (edema) of the cardiovascular and respiratory system; congestive heart failure, COPD, chronic liver disease
• Deep Vein Thrombosis (DVT) or known circulatory dysfunction
• Acute febrile respiratory (Flu like respiratory conditions) Acute kidney and urinary tract diseases
• Cold Allergenic Phenomenon (known allergy to cold contactants)
• Heavy consumerist diseases (abnormal bleeding)
• Bacterial and viral infections of the skin, wound healing disorders (open sores or discharging wound/skin conditions)
• Valvular heart disease condition after heart surgery
This list was developed as a consensus list at a Medical Symposium in 2006 and agreed upon in writing by twelve attendees. It of course may not be all inclusive, so if you have any particular health problem which you believe would preclude you from participating in exposure to extreme cold, please check with your treating physician before participating.
I HAVE READ, UNDERSTOOD, AND ACKNOWLEDGE THE ABOVE INFORMATION INCLUDING THE ABSOLUTE CONTRAINDICATIONS. I AFFIRM THAT I DO NOT HAVE ANY OF THE CONDITIONS LISTED IN THE ABSOLUTE COTRAINDICATIONS SECTION.
LIABILITY AND INDEMNIFICATION AGREEMENT
In consideration for being permitted by Chiltonic to participate in a voluntary Cryotherapy activity, I hereby waive any and all claims and damages for personal injury or death which may occur as a result of my participation. I understand and agree that:
This release is intended to discharge in advance Chiltonic, its' officers, officials, employees, agents and volunteers from and against all liability arising out of or connected in any way with my participation in these activities.
Participation may involve risk of serious injury, illness, disability or death and may result not only as a result of my actions, negligence or inaction, but also from the action, negligence or inaction of others, including their owners, officers officials employees, or volunteers and may result from the conditions of the facilities, equipment, or areas where such activities are being conducted. Knowing the risks involved and the contraindications related, I nevertheless chose voluntarily to request permission to participate.
I will indemnify and hold harmless Chiltonic, its' owners, officers, officials, employees and volunteers from any loss, liability, damage, cost or expense, including litigation of any form, arising out of or connected in any manner with my participation in such activities.
I am in good health and have no physical condition expressed in the 'Contraindications' or otherwise which would preclude me from safely participating in such activities.
I understand and agree that this release is intended to be as broad and inclusive as permitted under law and that if any portion of this Hold Harmless, Release and Indemnification Agreement should be determined to be invalid, it is my intent that the remaining provisions shall continue in full force and effect.
I HAVE CAREFULLY READ THIS RELEASE INDEMNIFICATION AND HOLD HARMLESS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A POTENTIAL CONFLICT BETWEEN MYSELF, AND MY HEIRS AND CHILTONIC, I VOLUNTARILY AGREE TO EACH OF THE TERMS AND PROVISIONS HEREIN AND SIGN THIS OF MY OWN FREE WILL.
We acknowledge that we are not medical professionals and that we can only share with you what positive results we have seen historically with clients. We are only offering access to the therapy with no promises of any results. Every client is different and responds differently to the therapy.
I have completely read this waiver.
Sign your first and last name below as your representation that you have read and agree to the waiver in its entirety.