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 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.
ABSOLUTE CONTRAINDICATIONS FOR WHOLE BODY CRYOTHERAPY ONLY: (Localized treatments have no contraindications)
Please check "No" for all of the following conditions to be able to participate in Whole Body Cryotherapy:
Severe Cardiovascular Conditions:
No Untreated Hypertension
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.
Please let technician know if you have/are:
Hyperhidrosis – heavy perspiration
Cold Allergenic Phenomenon (know allergy to cold)
Open Sores, Wounds or Blisters
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 or taking medication, which you believe, would preclude you from participating in exposure to extreme cold, please check with your treating physician before participating.
LIABILITY AND MEDICAL RELEASE AND INDEMNIFICATION AGREEMENT
In consideration for being permitted by ICEBOX Cryotherapy to participate in their Cryotherapy and attend their exercise and stretching activity. I hereby waive any and all claims and damages for personal injury and death, which may occur, as a result of my participation. I understand and agree that:
1. This release is intended to discharge in advance ICEBOX Cryotherapy, it’s 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;
2. 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.
3. Knowing the risks involved and the contraindications related, I nevertheless chose voluntarily to request permission to participate.
4. I will indemnify and hold harmless ICEBOX Cryotherapy, 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.
5. 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.
6. 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 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 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