City: State: Zip:
Date of Birth:
How did you hear about ICEBOX? (if recommended by a friend please name so we can thank them)
What's the reason for your visit?
Improve recovery & performance
Pain & Inflammation Reduction
Chronic Skin Condition Treatment
Skin Aging and Cellulite Reduction
WAIVER AND RELEASE AGREEMENT
PLEASE READ CAREFULLY BEFORE SIGNING
This is a release of liability and waiver of certain legal rights:
Participation in Cryotherapy session(s) involves exposure to extreme cold temperature for a short period of time (not to exceed (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 walk out of the chamber at any time. Skin burns or Nips are not common during a Cryotherapy session, but if a client has skin sensitivity or has not fully removed moisture, lotions or medicine from skin, Skin Nips (like a sunburn) can occur.
ABSOLUTE CONTRAINDICATIONS FOR WHOLE BODY CRYOTHERAPY ONLY: (Localized treatments have no contraindications)
Please verify that you do not have, nor have you had any of the following conditions in order to participate in Whole Body Cryotherapy or other Icebox services. As appropriate, identify by marking "No" for all of the following conditions to be able to participate in Whole Body Cryotherapy:
Severe Cardiovascular Conditions:
No Untreated Hypertension (high blood pressure)
No Peripheral Arterial Occlusive Disease
No Valvular Heart Disease
No Heart Attack within previous 6 months
No Unstable Angina Pectoris
No Ischemic Heart Disease
No Condition after heart surgery
No Decompressing heart failure, COPD, chronic liver disease
No Valvular heart disease
No Deep Vein Thrombosis or known circulatory dysfunction
No Bacterial and viral infections of the skin, wound healing disorders
No Open sores or discharging wound/skin conditions
No Severe Anemia
No Heavy consumerist diseases (abnormal bleeding)
Conditions of the Nervous System/Kidney & Liver Function:
No Acute kidney and urinary tract diseases
No Seizure Disorders
Other General Health Conditions:
No Drug relative contraindications
I ACKNOWLEDGE I DO NOT HAVE ANY OF THE CONDITIONS ABOVE. IF I DO HAVE ANY OF THE CONDITIONS ABOVE, MY PARTICIPATION IN ICEBOX CRYOTHERAPY IS PROHIBITED UNTIL I PROVIDE A PHYSICIAN'S RECOMMENDATION.
Please let technician know if you have/are:
Hyperhidrosis – heavy perspiration
Cold Allergenic Phenomenon (know allergy to cold)
Open Sores, Wounds or Blisters
Since ICEBOX Cryotherapy is no longer monitoring blood pressure, please let the technician know if you want to check your blood pressure prior to utilizing the cryotherapy machines. A blood pressure cuff will be provided for your use.
This list is not all inclusive, so if you have any particular health problem not listed above, or are taking medication that you believe would preclude you from participating in exposure to extreme cold, please consult with your treating physician before participating.
WAIVER OF LIABILITY RELEASE AND INDEMNIFICATION AGREEMENT
In consideration for being using ICEBOX Cryotherapy and participating in and attending the related therapy and activity, I hereby release, waiver, discharge and hold harmless ICEBOX Cryotherapy from any and all liability claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury that may be sustained by myself or any person, while using Cryotherapy equipment, or due to the use of the Cryotherapy equipment.
1. This release is intended to discharge in advance ICEBOX Cryotherapy, its officers, directors, owners, officials, employees, agents and volunteers from and against any and all liability arising out of or connected in any way with my participation in Cryotherapy activities, including but not limited to the use of the cryotherapy equipment, and related therapies and activity (the "Activities");
2. Participation in the Activities may involve risk of serious injury, illness, disability or death and such risks may the result of the actions, inaction, negligence of myself or others, including the Releasees, or hte conditions of the facilities, equipment, or areas where the Activities are conducted.
3. Knowing the risks involved and the possibility of contraindications, I nevertheless voluntarily chose to participate in the Activities and I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury that may be sustained.
4. I hereby indemnify and hold harmless the Releasees 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 the Activities.
5. It is my express intent that this Waiver of Liability and Release and Hold Harmless Agreement shall bind all members of my family and spouse (if any), if I am alive, and my heirs, assignees, and personal representative. If I am not alive, and shall be deemed as a RELEASE, WAIVER, AND DISCHARGE of the above named Releasees.
6. I am in good health and have no physical condition expressed in the 'Contraindications' or otherwise which would preclude me from safely participating in the Activities.
7. I understand and agree that this release is intended to be as broad and inclusive as permitted under Georgia law and that if any portion of this Waiver, 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 hereby further agree that this Waiver of Liability and Release and Hold Harmless Agreement shall be construed in accordance with the laws of the state of Georgia.
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 ICEBOX CRYOTHERAPY. I VOLUNTARILY AGREE TO EACH OF THE TERMS AND PROVISION HEREIN AND SIGN THIS OF MY OWN FREE WILL.
Sign your first and last name below as your representation that you have read and agree to the waiver in its entirety.
Copyright 2014 Icebox Cryotherapy