CONFIDENTIAL
MINOR WAIVER / RELEASE OF LIABILITY
Date:
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
Minor Name <CHILDFIRSTNAME> <CHILDLASTNAME>
Have you had a whole body cryotherapy session before? Yes No
If "yes", how many cryotherapy sessions have you completed? 1-5 6-15 >15
How did you hear about Cryotherapy of Wisconsin?
If another client referred you to us, who can we thank?
What is the primary store you will be visiting?
What are your goals/what are you hoping to improve from cryotherapy?
What are your interests and hobbies?
Are you currently or within the last week exhibiting any symptoms such as: cough, fever, chills or runny nose?
Yes No
If yes, please specify what and for how long?
Are you taking any medicines at the moment? Yes No
If yes, please specify what and for how long:
Have you had any injection within the last 3 days? Including but not limited to Botox (or similar injectables), cellulite reduction,weight loss procedures, implants, etc.
Yes No
If yes, please specify:
Do you feel well/healthy at the moment? Yes No
If not, please comment:
Are you currently under medical care for any reason? Yes No
If yes, please explain:
If you are female, ARE YOU PREGNANT? Yes No
DO YOU HAVE – OR – HAVE YOU EVER HAD… (Check if answer is yes):
Do you have any specific questions about Cryotherapy?
We welcome walk-ins for Whole body Cryotherapy Sessions (if you are a current client). All other servcies are by Appointment Only.
Initials
For any Cryo T-Shock service, we request a 24 hour Cancellation Notice or there could be up to a $200.00 re-scheduling fee.
Initials
All packages expire one year from date of purchase.
Initials
WHAT IS WHOLE BODY CRYOTHERAPY?
Whole body cryotherapy is the exposure of a person’s skin to temperatures of -130° to -170° Celsius (-238° to -274° Fahrenheit) for a short time (3 minutes or less). At this temperature, the body activates several mechanisms that have significant long-term medical and cosmetic benefits:
The outer skin reacts to the cold by activating an increased production of collagen in deeper layers of the skin (similar to laser treatments of the face, where very high temperatures are used). The skin regains elasticity and becomes smoother and even-toned, significantly improving conditions such as cellulite and skin aging.
Skin vessels and capillaries undergo severe vasoconstriction (to keep the core temperature from dropping), followed by vasodilation after the procedure. Toxins and other stored deposits are flushed out of the layers of the skin and blood perfusion is improved after several treatments.
The anti-inflammatory properties of cryotherapy are also used to treat chronic skin conditions such as psoriasis and dermatitis.
SAFETY INSTRUCTIONS FOR CRYOTHERAPY
- You must wear cotton socks and gloves to avoid chilblain.
- Treatments are limited to 3 minutes per session. Overexposure to the cold temperatures may cause chilblain;
- During treatment, you must avoid inhaling the nitrogen fumes; while non-toxic, they are devoid of oxygen and may cause fainting;
- You may end the procedure at any time if you experience any problems or anxiety;
- Abnormal skin sensitivity to cold may be caused by certain food, cosmetics, or medication, including but not limited to the follow: Tranquilizers, High blood pressure medication;
- A person who is less than (18) years of age may not use whole body cryotherapy without parental consent.
ABSOLUTE CONTRAINDICTIONS TO USING WHOLE BODY CRYOTHERAPY
Pregnancy, severe Hypertension (BP>150/90), acute or recent myocardial infarction (heart attack; need to be cleared for exercise), arrhythmia, symptomatic cardiovascular disease, acute or recent cerebrovascular accident (stroke, need to be cleared for exercise), uncontrolled seizures, fever, symptomatic lung disorders, bleeding disorders, infection, claustrophobia, intolerance to cold, age less than 18 years (parental consent to treatment needed), incontinence.
POSSIBLE RISKS OF WHOLE BODY CRYOTHERAPY
Fluctuations in blood pressure (due to peripheral vasoconstriction, blood pressure may briefly increase by up to 10 points systolically during treatment. This effect should reverse after the end of the procedure, as peripheral circulation returns to normal, allergic reaction to extreme cold (rare), claustrophobia, anxiety, activation of some viral conditions (cold sores) etc. due to stimulation of the immune system.
Normatec Pulse Compression Therapy Contraindications
Do not use Normatec Pulse Compression Therapy if you have or may have any of the following conditions: current or unstable fractures or breaks, DVT, recent surgery and have sutures or stiches, open wounds, contusions, or abrasions. If you have any other injury, illness or medical condition, you should consult your physician prior to using NormaTec.
Facial and Localized Cryotherapy Contraindications
Do not use Localized Cryotherapy if you have or may have any of the following conditions: cryoglobulnemia, cold hemaggulation or cold hemolysis, cold-induced itching, impaired arterial blood flow as from stage II, Raynaud’s Disease, severe sensory disorders, trophic disorders or hypersensitivity to cold. If you have any other injury, illness or medical condition, you should consult your physician prior to using localized cryotherapy
Body Pod Contraindications
We make no claims that the BodyPod corrects or cures any disease. Persons sensitive to light and heat should use caution. You are required to remove all exterior metal while in the pod: Jewelry, wire bra, etc. DO NOT USE IF YOU ARE PREGNANT. DO NOT USE IF YOU HAVE: INFECTIOUS OR CONTAGIOUS SKIN CONDITIONS, ACTIVE CANCER, PACEMAKERS AND DEFIBRILLATORS, EPILEPSY, HEMOPHILIA, INDIVIDUALS WITH SENSITIVE SKIN OR POOR BLOOD CIRCULATION, HEART CONDITION, ERYTHEMA (superficial reddening of the skin, ususually in patches), INTOXICATION. A DOCTORS CONSENT is needed if you are using medication such as barbiturates or beta blockers. INFRARED LIGHT HAS BEEN SHOWN TO FADE TATTOOS. DO NOT USE if you are concerned about fading.
LED Bed Contraindications
Pregnancy, cancer, Immunosuppressant drugs / photodynamic therapy, steroid injections (Must wait 48 hours after the injection). It's recommended to consult your doctor if you have breast implants before using any LED light bed and/or infrared heat.
WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT
1. In consideration for using the cryo device (Equipment), I hereby RELEASE, WAIVE, DISCHARGE IN ADVANCE, and HOLD HARMLESS Cryotherapy of Wisconsin, LLC (hereinafter referred to as RELEASEE) along with its DBA’s, OFFICERS, OFFICIALS, EMPLOYEES, AGENTS, FRANCHISEE’S and VOLUNTEER’S from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any damage or injury that may be sustained by me, 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 cryo process. I have been explained and 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 acknowledge and understand that All Packages and Paid In Full Memberships Expire 1 year from date of purchase. The Game Changer Package is for Whole Body Cryotherapy only, can be used every day we are open, and expires 5 weeks from date of purchase. Monthly and Annual Memberships Expire each month from date of purchase. These sessions do not rollover into the next month.
4. I am fully aware of the risks connected with the use of the Equipment, 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 that may be engaged in such activity.
5. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEE from any costs that may incur due to the use of Equipment by me.
6. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and shall be deemed as a RELEASE, WAIVER, AND DISCHARGE of the above named RELEASEE. 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 Wisconsin.
7. 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. If I should faint due to excess nitrogen inhalation, I hold myself responsible for all injuries should I fall, and the cryosauna attendant has the right to assist me. My signature below constitutes my acknowledgment that (1) I have read, understand, and fully agree to the foregoing CONSENT, (2) the proposed indoor cryo process has been satisfactory 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.
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 (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 cryo device 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. By signing below, I affirm that I have read and fully understand the risks as outlined in this waiver. I VOLUNTARILY AGREE TO EACH OF THE TERMS AND PROVISIONS HEREIN AND SIGN THIS OF MY OWN FREE WILL.
Intials I understand packages expire I year from the date of purchase.
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
Participant’s Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Signature:
Date:
PARENTAL CONSENT FORM FOR CHILDRENT (UNDER AGE 18)
Note: Minor children must be over 14 years old to participate in Whole Body Cryotherapy unless we receive a doctor's consent in writing.
I, (Parent or Legal Guardian), , acknowledge that I have read and understand the Cryotherapy of Wisconsin, LLC waiver and acknowledge the risk associated with Cryotherapy treatment.
My son/daughter (participant listed above) has also read and acknowledged the contraindications and waiver of risk. I give consent on behalf of my minor to voluntarily undergo treatment:
Parent/Guardian Signature:
Date: