THERAPY WAIVER AND CONSENT FORM
What issues do you have to address through Cryo therapy?
Safety Instructions for Whole Body Cryotherapy
1. You must wear cotton or wool socks (and underwear for men) to avoid chilblain.
2. Treatments are limited to 3 minutes per session. Over exposure 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. During treatment, you must keep your hands visible to the operator at the upper rim of the Cryosauna as instructed.
5. You may end the procedure at any time if you experience any problems or anxiety.
6. 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.
7. A person who is less than (18) years of age may not use whole body cryotherapy without parental consent.
Contraindications of using Whole Body Cryotherapy
Pregnancy, server Hypertension (BP > 180/100), 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, Ryanaud’s Syndrome, fever, tumor disease, symptomatic lung disorders, bleeding disorders, bleeding disorders, severe anemia, infection, claustrophobia, cold allergy, age less than 18 years (parental consent to treatment needed), acute kidney and urinary tract disease.
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 condition (cold sores) etc. due to stimulation of the immune system.
WAVIER OF LIABILITY AND HOLD HARMLESS AGREEMENT
1. In consideration for using the cryo device (Equipment), I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS Cryosaua, LLC, its officers, servants, agents, employees and volunteers (hereinafter referred to as RELEADEES) from any and all liability, claims, demand, 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 cryo process, 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 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, 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 RESPONSIBLITTY 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 activity.
4. I further herby 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.
5. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assignees and personal representative, if I am not alive, and shall be deemed as a RELEASE, WAVIER, AND DISCHARGE of the above named RELEASSES. I hereby further agree that this Wavier of Liability and Hold Harmless Agreement shall be constructed in accordance with the laws of the State of TEXAS.
6. I understand that the RELEASEES will not be responsible for any medical costs associated with any injury.
7. I understand with Whole Body Cryotherapy is provided for the basic purpose of relaxation, stress reduction, relief of muscular tension, recovery from muscular tension, and recovery from surgery, illness or injury. I further understand that Whole Body Cryotherapy should not be construed as a substitute for medical examination diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.
8. I understand that Whole Body Cryotherapy therapist are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such.
9. Because Whole Body Cryotherapy is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so.
My signature below constitutes my acknowledgement that (1) I have read, understand, and fully agree to the foregoing CONSENT, (2) the proposed indoor cryo process has 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 manufactures, from any damage or harm that I might incur due to the use of the facilities.
IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND RREPRESENT THAT I have read and understand the foregoing Wavier of Liability and Hold Harmless Agreement, I am at least eighteen (18) years of age and fully competent; I have given up considerable future legal rights; and I execute this Release freely, voluntarily, under no duress or threat of duress without inducement, promise or guarantee being communicated to me.
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.