
CLIENT INTAKE AGREEMENT (CORE SERVICES)
I. DEMOGRAPHIC INFORMATION
DATE:
CLIENT’S NAME (Referred to as “You” or “Client” throughout Client Intake Agreement):
Last Name
First Name
BIRTHDATE:
ADDRESS:
CELL PHONE:
E-MAIL*:
*If you provide your e-mail and/or cell phone to us, we may use such information to contact you by e-mail and/or text for marketing of services provided by HydroLight Lounge, LLC (“HydroLight Lounge”).
II. CLIENT HISTORY
Are you currently pregnant? Yes No
Are you currently taking any medications or supplements? Yes No
If yes, you acknowledge that HydroLight Lounge does not review medications and that you are responsible for confirming any medication-related safety concerns with your physician as needed.
Please see the contraindications listed on Exhibit A, attached hereto and incorporated by this reference. If you are experiencing any of the contraindications listed on Exhibit A, you must refrain from receiving the Services or obtain a written note from your Physician authorizing your receipt of the Services notwithstanding such contraindications.
Are you experiencing any of the contraindications listed on Exhibit A? Yes No
If yes, please list the contraindications:
If yes, do you have a written note from your Physician authorizing your receipt of the Services? Yes No
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ THE CONTRAINDICATIONS LISTED ON EXHIBIT A AND REPRESENT AND WARRANT (A) THAT I AM NOT EXPERIENCING ANY SUCH CONTRAINDICATIONS OR (B) THAT I HAVE PROVIDED HYDROLIGHT LOUNGE WITH A WRITTEN NOTE FROM MY PHYSICIAN AUTHORIZING MY RECEIPT OF THE SERVICES NOTWITHSTANDING SUCH CONTRAINDICATIONS.
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III. SERVICES
HydroLight Lounge providers work with clients to provide water and/or light-based therapies (including, but not limited to, cold plunge, infrared sauna, and red light and contrast therapy) (the “Services”). I understand that HydroLight Lounge providers do not provide professional medical advice, diagnosis or treatment. I understand to always seek the advice of my physician or other qualified health provider with any questions I may have regarding a medical condition.
IV. IN-LOUNGE SERVICE POLICY
You acknowledge and agree that you will not receive services while under the influence of alcohol, recreational drugs, or any impairing substance, and that doing so may pose health and safety risks. You further acknowledge that HydroLight Lounge is a smoke-free and vape-free facility and agree not to smoke or vape while inside the facility at any time.
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V. CLIENT RESPONSIBILITY TO UPDATE HEALTH INFORMATION
You acknowledge that it is your responsibility to inform HydroLight Lounge of any changes to your health status, medications, contraindications, or other relevant medical information after signing these agreements. You agree to complete updated intake forms as required to ensure the continued safe provision of services.
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VI. CASH BUSINESS/NO INSURANCE/FINANCIAL RESPONSIBILITY
I understand that HydroLight Lounge only accepts cash or credit card for the Services and payment is required at the time the Services are rendered. I have been provided with a fee schedule for the Services. I further understand that HydroLight Lounge is not a participating provider with any insurance plans and will not file any insurance claims for the Services rendered through HydroLight Lounge. I understand that in consideration of the Services provided to Client, I am directly and primarily responsible to pay the amount of all charges incurred for services and procedures rendered by HydroLight Lounge. I further understand that HydroLight Lounge does not guarantee that any payment for HydroLight Lounge services will be credited towards satisfying any deductible of Client’s insurance plan.
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VII. DISPUTE RESOLUTION
THE PARTIES AGREE THAT ANY DISPUTE ARISING UNDER THIS AGREEMENT OR OTHERWISE RELATED TO THE SERVICES RENDERED WILL BE HEARD AND DECIDED BY A JUDGE ONLY AND WAIVE THEIR RIGHTS TO TRIAL BY JURY.
This Agreement shall be governed by and construed in all respects by the laws of the State of Florida.
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VIII. CLIENT SIGNATURE
BY SIGNING THESE CLIENT INTAKE AGREEMENTS, I ACKNOWLEDGE THAT I HAVE CAREFULLY READ, UNDERSTAND AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT.
Client Name:
Date:
Client Signature:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
EXHIBIT A
CONTRAINDICATIONS
PLEASE READ CAREFULLY. If you are experiencing any of the below listed contraindications, please notify a HydroLight Lounge staff member.
Please check with your physician before receiving the Services if you have a particular health problem which is not listed below but which you believe may preclude you from receiving any of the Services.
1. COLD PLUNGE
a. You are required to refrain from receiving cold plunge services if you are:
i. Pregnant;
ii. Under the influence of alcohol, prescription medication or other impairing chemical substance; or
Iii. Currently diagnosed with any of the following:
1. Hypertension;
2. Raynaud’s disease; or
3. Cardiac or pulmonary conditions.
b. Please be advised:
i. HydroLight Lounge does not recommend that you spend more than seven (7) minutes in cold plunge during any one (1) session.
ii. Individuals who are breastfeeding may experience decreased milk supply following cold plunge services.
2. RED LIGHT THERAPY
a. You are required to refrain from receiving red light therapy services if you are:
i. Pregnant or breastfeeding;
ii. Photosensitive;
iii. Using topical, oral, or injectable steroids;
iv. Using Tetracycline, Digoxin, Retin A and/or any other photosensitive medications;
v. Recovering from any Lasik eye surgery or any other surgical treatment;
vi. Experiencing a fever;
vii. Recovering from any recent burn; or
viii. Currently diagnosed with any of the following:
1. Epilepsy (or have a history of seizures);
2. Hyperthyroidism;
3. Eye disease;
4. Systemic lupus erythematosus (SLE); or
5. Cancer.
b. You are required to refrain from receiving red light therapy services if you have received Botox or any other cosmetic fillers within the five (5) day period prior to receiving red light therapy services.
c. Please be advised:
i. Individuals with breast implants should consult with their physician prior to receiving red light therapy.
ii. Individuals with tattoos may be prone to skin blistering or may experience tattoo fading. Tattoo locations should be covered prior to treatment.
iii. Individuals with herpes may experience activation of dormant virus.
iv. The effects of red light therapy of skin pigmentation is still being studied. Individuals with hyperpigmentation may desire to discontinue red light therapy services if this is a concern.
3. LIGHT THERAPY
a. You are required to refrain from receiving light therapy services if you are:
i. Under the age of eighteen (18);
ii. Using cortisone injections or any other form of steroid injection(s); or
iii. Currently diagnosed with any of the following:
1. Epilepsy (or have a history of seizures); or
2. Cancer.
b. Please be advised, you are not recommended to receive light therapy services over the breast or stomach if you are currently pregnant or breastfeeding.
4. INFRARED SAUNA
a. You are required to refrain from receiving infrared sauna services if you are:
i. Under the age of twelve (12);
ii. Pregnant or breastfeeding;
iii. Wearing a pacemaker or defibrillator;
iv. Recovering from any joint injury received during the forty-eight (48) hour period prior to receiving infrared sauna services;
v. Experiencing a fever;
vi. Prone to bleeding;
vii. Insensitive to heat;
viii. Equipped with any implants (including, but not limited to metal pins, rods, artificial joints or any other surgical implants);
ix. Using diuretics, barbiturates, beta-blockers or anticholinergic medications;
x. Under the influence of alcohol or other impairing chemical substance; or
xi. Currently diagnosed with any of the following:
1. Any cardiovascular condition (including, but not limited to, hypertension, hypotension, congestive heart failure and impaired coronary circulation);
2. Obesity;
3. Diabetes;
4. Hemophilia;
5. Decompensating disease (Edema) of the cardiovascular and respiratory system; or
6. Any chronic condition or disease associated with reduced ability to sweat or perspire (including, but not limited to, multiple sclerosis, central nervous system tumors and diabetes with neuropathy).
b. Please be advised:
i. Do not sleep inside of the sauna.
ii. The core body temperature of children rises much faster than adults. Individuals between the ages of twelve (12) and seventeen (17) must be accompanied by an adult.
iii. If you are currently menstruating, menstrual flow may be temporarily increased following infrared sauna services.
iv. The ability to maintain core body temperature decreases with age. If you are over the age of seventy (70), you should only use the infrared sauna at a reduced temperature and for short periods.
5. CONTRAST THERAPY
a. You are required to refrain from receiving contrast therapy services if you are:
i. Bleeding;
ii. Experiencing any acute inflammations;
iii. Prone to impaired sensation;
iv. Currently diagnosed with any of the following:
1. Peripheral vascular disease (PVD);
2. Diabetes;
3. Neuropathy; or
4. Cancer.
HYDROLIGHT LOUNGE, LLC
Consent and Release
I, as a client of HydroLight Lounge, LLC (the “Company”), hereby request and authorize the Company and/or such providers as designated by the Company to perform water and/or light-based therapies (including, but not limited to, cold plunge, colon hydrotherapy, infrared sauna, and red light and contrast therapy) (the “Services”) on my behalf.
I understand that in addition to the intended benefits, the Services may involve inherent risk of injury, illness or adverse reaction, including, but not limited to, nausea, dizziness, weakness, allergic reaction, electrolyte imbalance, perforation of the colon, infection and possible skin reactions including, but not limited to, pigment changes, redness, swelling, itching, pain, blistering, scabbing, scarring, acne and/or other irritations. These and other possible risks, on occasion, could be serious or even fatal. I voluntarily assume all risks associated with participating in the Services.
I understand that the Services are not appropriate for everyone. This depends on my health problem(s) and overall health condition. I understand that the Company does not evaluate or diagnose my health. I represent and warrant that I have received medical clearance prior to engaging in the Services. I understand that my participation in the Services is voluntary and that I have the right to refuse or discontinue participation at any time.
I represent and warrant that I have completely and accurately filled out all intake forms required by the Company. I acknowledge that the Company will rely, in part, on the information contained therein in providing the Services. If the Company determines that the Services are not appropriate for me, the Company may terminate the Services.
I understand that I will be responsible for payment in accordance with the terms of the Company’s policies and procedures. The Services from the Company are only to be paid on a cash basis.
I understand that there is never a warranty or guarantee as to a particular result or outcome related to the Services.
In the case of a suspected emergency during the provision of the Services, I authorize the Company to notify my emergency contact, local physician or to contact first responders. If during the provision of the Services, the Company feels that I might be experiencing any medical or clinical complications or emergencies, the Services will be terminated and I will need to seek treatment from a health care provider who can provide the appropriate level of service.
I agree that neither I, nor my legal representatives, including, but not limited to, my spouse, family, heirs, administrators, executors, representatives, assigns and agents will sue, make a claim against, or attach the property or assets of the Company for any illness, injury (including death), damages or losses I may incur, which arises out of the Services, regardless of whether caused or partially caused by the negligence or act or omission of the Releasees (as defined below), or otherwise. I understand and agree that this Consent and Release extends to all claims and demands referred to herein, of every kind and nature whatsoever, whether known or unknown, suspected or unsuspected.
I agree to release, forever discharge and hold harmless the Company and any of the Company’s members, managers, officers, employees, directors, subsidiaries, affiliates, successors, representatives, assigns and agents (collectively the “Releasees”), from any and all illness, injuries (including death), losses, damages, liabilities, claims, rights of action, causes of action of any nature, either in law or equity, and any penalties, judgments, costs and expenses (including reasonable attorneys’ fees), which arises out of the Services, regardless of whether caused or partially caused by the negligence or act or omission of the Releasees, or otherwise.
I fully understand that this Consent and Release means that I am giving up, among other things, my right to sue the Company for any illness, injury (including death), damages or losses I may incur related to the Services. I also understand that this Consent and Release binds my spouse, family, heirs, administrators, executors, representatives, assigns, and agents as well as me.
In the event that the client is a minor, then I, hereby represent that I am the parent, guardian or legal representative with the legal authority to consent and contract on behalf of the minor client. As the undersigned parent, guardian or legal representative of the minor named above, I hereby make and enter into each and every agreement, representation, waiver and release set forth herein on behalf of myself and the minor intending that they be binding on me, the minor, and our relatives, heirs, administrators, executors, representatives, assigns and agents. By signing below, I represent that I give up my right and the right of minor, to maintain any claim or suit against the Releasees arising out of minor’s participation in any of the Services or related in any way to minor’s involvement with the Company. I further agree to hold harmless, defend, and indemnify the Releasees of and from any claims from third parties arising from or related to the minor’s involvement in any of the Services.
I AGREE THAT ANY DISPUTE ARISING UNDER THIS CONSENT AND RELEASE OR OTHERWISE RELATED TO ANY WATER AND LIGHT-BASED THERAPIES THAT I RECEIVE FROM THE COMPANY (INCLUDING, BUT NOT LIMITED TO, cold plunge, colon hydrotherapy, infrared sauna, and red light and contrast therapy) WILL BE HEARD AND DECIDED BY A JUDGE ONLY AND I WAIVE MY RIGHTS TO TRIAL BY JURY.
This Consent and Release shall be governed by and construed in all respects by the laws of the State of Florida.
I have read this Consent and Release and I have been given the opportunity to have all my questions answered to my satisfaction.
BY SIGNING THIS CONSENT AND RELEASE, I ACKNOWLEDGE AND CERTIFY THAT I UNDERSTAND AND AGREE TO ALL OF THE ABOVE TERMS AND CONDITIONS AND THAT I HAD THE OPPORTUNITY TO HAVE QUESTIONS ANSWERED TO MY SATISFACTION.
“CLIENT”
Client Signature:
Print Name of Client:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Parent, Guardian or Legal Representative’s Signature:
Print Name of Parent, Guardian or Legal Representative:
Date: