Waiver of Liability and Release of Claims
1. I have independently decided to use cryotherapy devices, including, but not limited to, NormaTec, provided by Cryotherapy Advantage, LLC, (“Equipment”) as a non-medical treatment for purposed of . I understand that Whole Body Cryotherapy is generally thought to provide relaxation, stress reduction, relief of muscular tension, recovery from muscular tension, and recovery from surgery, illness or injury in some circumstances (“Whole Body Cryotherapy”).
2. I have investigated the benefits and risks of cryotherapy treatment for myself, and I execute this Waiver and Release with the full assumption of the risk of any injury that I or any other person may sustain, including, but not limited to, all injuries identified in this document and in the sections where I place my initials below.
3. I intend for this Waiver and Release to be a clear statement of my assumption of risk in addition to a Waiver of Liability and Release of Claims in favor of Cryotherapy Advantage. I fully appreciate the nature and extent of the risks from cryotherapy, and I voluntarily execute this Waiver and Release.
4. I hereby release Cryotherapy Advantage, LLC, its owners, officers, servants, agents, employees, representatives and volunteers (“Cryotherapy Advantage”) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, cost, or injury, that I or any other person may sustain, while using the Equipment or due to the use of the Equipment or any related or ancillary product or service offered by Cryotherapy Advantage.
5. I hereby confirm that no warranty, representation or guarantee, or any other assurance or prediction of outcome has been made to me concerning the results of cryotherapy treatments and that I am fully aware of the risks and hazards connected with the use of the Equipment, including the risk of physical injury or disability and/or death as the result of such use, and I am voluntarily participating in the Equipment usage, and entering the above named premises to engage in such usage.
6. 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.
7. I expressly agree that this Waiver and Release not only binds me, but it also binds my spouse, family and my heirs, assignees and personal representative if I am not alive.
8. I understand that Cryotherapy Advantage, will not be responsible for any medical or incidental costs associated with any injury I may sustain due to the use of the Equipment and/or any of the devices at the Cryotherapy Advantage office.
9. I understand that the Equipment is designed for possible fitness and appearance enhancing, and that the Equipment should be used only by persons in good general health.
10. I have been advised by reading this form, and I have investigated for myself, that if I suffer from any medical condition or illness whatsoever; I am not to use the Equipment without my doctor’s written permission.
11. If I faint due to excess nitrogen inhalation, I hold myself responsible for all injuries that result from falling, collapsing, and also from injuries caused by the excess nitrogen inhalation.
12. I understand that I take full responsibility for all damage that I or my guests or invitees may commit or cause while at the Cryotherapy Advantage office. I expressly agree to pay immediate restitution to the owners for any and all damages.
13. I understand that the physical and mental conditions discussed herein and on cryotherapyadvantage.com are representative of commonly known and studied applications and symptoms, but Whole Body Cryotherapy aka Cryosauna is not represented or guaranteed to diagnose or cure specific diseases, symptoms or conditions.
14. I received no medical advice from Cryotherapy Advantage.
15. I understand that it is possible that I may receive no benefit from my use of the Equipment.
16. In the event of any litigation arising out of the terms of this agreement, the prevailing party in such litigation shall be entitled to recover all reasonable attorney’s fees and costs incurred against the non-prevailing party, including fees and costs incurred on appeal.
17. I expressly agree that this Waiver and Release is governed by Virginia law, and exclusive venue is in Fairfax County, Virginia.
18. Cryotherapy Advantage has recommended that I consult with a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of, or if I have any questions as to the benefits or risks of Whole Body Cryotherapy. I also understand that Whole Body Cryotherapy should not be construed as a substitute for medical examination, diagnosis, or treatment.
19. I understand and expressly agree that I use the Equipment and all cryotherapy devices at my own risk.
20. I acknowledge and represent that I have read and fully understand the foregoing Waiver of Liability and Release of Claims, and I am at least eighteen (18) years of age and fully competent.
21. I acknowledge that if there is anything in this Waiver and Release, or in the sections below where I place my initials, that I do not understand, I will consult with an attorney and/or physician before signing this agreement.
22. Yes No I hereby grant Cryotherapy Advantage permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration.
|Participant’s Full Name:
Safety Instructions for Whole Body Cryotherapy:
1. You must wear cotton or wool socks and gloves provided by Cryotherapy Advantage, (and underwear in men) to avoid chilblain;
2. Treatments are limited to 3 minutes per session. Overexposure to the cold temperatures may cause chilblain;
3. During treatment, you must avoid inhaling the nitrogen fumes; while non-toxic, they are devoid of oxygen and may cause fainting;
4. You may notify the attendant to end the procedure at any time if you experience any problems or anxiety;
5. Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, or medication, including but not limited to the following: Tranquilizers, High blood pressure medication
6. A person who is less than (18) years of age may not use whole body cryotherapy without parental consent;
7. Do not touch any objects in the cryocabin with your unprotected skin.
Contraindications to using Whole Body Cryotherapy:
Pregnancy, severe Hypertension (BP> 150/90), acute or recent myocardial infarction, unstable angina pectoris, arrhythmia, symptomatic cardiovascular disease, cardiac pacemaker, peripheral arterial occlusive disease, venous thrombosis, acute or recent cerebrovascular accident, uncontrolled seizures, Raynaud’s Syndrome, cold, fever, tumor disease, symptomatic lung disorders, bleeding disorders, severe anemia, infection, claustrophobia, cold allergy, age less than 18 years (parental consent to treatment needed), acute kidney and urinary tract diseases., cold-induced asthma, open wound or sore (including teeth abscesses, hyperthyroidism, acute respiratory disease peripheral arterial disease (Fontaine Stages III & IV ), bacterial and viral skin infections, under the influence of drugs or alcohol, Heart attack which dates less than 6 months, Polyneuropathy, low white blood cell count.
Contraindications to using NormaTec:
Acute pulmonary edema, acute thrombophlebitis, acute congestive cardiac failure, acute infections, Deep Vein Thrombosis, episodes of pulmonary embolism, wounds, lesions or tumor at or in the vicinity of application, where increased venous and lymphatic return is undesirable, bone fractures or dislocations at or in the vicinity of application.
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, frost bites, activation of some viral conditions (cold sores) etc. due to stimulation of the immune system or any unforeseen, known, or unknown risks.
How did you hear about Cryotherapy Advantage?
Approximately how far did you travel to Cryotherapy Advantage?
< 5 miles
Do you participate in any sports or other types physical activity?
REASON FOR VISIT:
- Muscle Soreness
- Pain Management
- Injury Rehabilitation Tool
- Improve Sleep
- Increase Energy
- Metabolic Boost
DO YOU HAVE A SPECIFIC INJURY? Yes No
WHEN DID YOUR SYMPTOMS START?(approximate date):
DO YOU GET PAIN WITH (Check all that applies):
WHAT TREATMENTS HAVE YOU HAD FOR THIS PROBLEM (Check all that applies):
PAST MEDICAL HISTORY: (Please check all of the following medical conditions that apply to you)
PAST SURGERIES AND APPROXIMATE DATES: