MEDICAL HISTORY AND CONSENT
How did you hear about us?
List the medications you are now taking and the respective doses:
Are you currently under medical care for any reasons? If yes, please explain:
*** DO NOT USE IF YOU HAVE ONE OF THE FOLLOWING ***
If you have checked any of the above, please explain:
Do you have or have you had any of the following illnesses?
Other serious illnesses (Please Explain):
Waiver of Liability and hold Harmless Agreement:
1. In consideration for using all services offered by Alpharetta Cryotherapy LLC or Roswell Cryotherapy LLC that may include but are not limited to Whole Body Cryotherapy, CryoFacials, Localized Cryotherapy, Infrared Sauna, Celluma Pro, NormaTec Recovery, Photobiomodulation and all related Equipment, I hereby release, waive, discharge, and hold harmless Alpharetta Cryotherapy LLC or Roswell Cryotherapy LLC, its officers, servants, agents, employees and volunteers (hereinafter referred to as releasees) 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 any person, while using the equipment or due to the use of the equipment.
2. I hereby confirm that no warranty or guarantee, or other assurance, has been made to me covering the results of the services provided, and I hereby relieve them and hold them harmless from all liabilities for injury or damage that may occur to me. I fully understand the administration of the process, including possible adverse reactions, side effects, or other possible complications. It is understood that this consent is being given in advance of any administration of the process, and is being given by me voluntarily to use the Equipment.
3. I am fully aware of the risks and hazards connected with the use of the Equipment, including the risk of physical injury or disability as the result of such injury, and I am voluntarily participating in said Equipment usage, and entering the above named premises to engage in such usage. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury that may be sustained, or any loss or damage to property as a result of being engaged in such an activity. I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs that may incur due to the use of Equipment by me.
4. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse, 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. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Georgia.
5. I understand that the releasees will not be responsible for any medical costs associated with any injury.
6. I understand that the Equipment is designed for fitness and appearance enhancing use only by persons in good general health. I have been advised that if I suffer from any medical condition or illness whatsoever, I am not to use the Equipment without my doctor’s written permission.
My signature below constitutes my acknowledgment that (1) I have read, understand, and fully agree to the foregoing consent, (2) the proposed Equipment proccesses have been satisfactorily explained to me and I have all of the information I desire and (3), I hereby give my authorization and consent. This consent shall stand as long as I use the Equipment at the location now and in the future.
I have read the instructions for proper use of the facilities and do so at my own risk and hereby release the owners, operators, franchisers, or manufacturers, from any damage or harm that I might incur due to use of the Equipment.
In signing this release, I acknowledge and represent that I have read and understand the foregoing Waiver of Liability and Hold Harmless Agreement, I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same.
Furthermore, I agree that I will comply with all instructions on the use of the Equipment and that I am using these services at my own risk. I agree to use all sessions within the terms of the contract dates and understand that refunds are not given on unused portions of purchased packages.