The Fix LLC
Obermeyer Place – 501 Rio Grande Place, Suite 105 – Aspen, CO 81611
LIABILITY RELEASE, WAIVER AND INDEMNIFICATION,
EXPRESS ASSUMPTION OF RISK AND CONSENT TO USE LIKENESS
THIS WAIVER AND RELEASE SPECIFICALLY INCLUDES ANY AND ALL NEGLIGENCE, BY WAY OF ACTION OR INACTION, BY ANY OWNERS, MEMBERS, MANAGERS, INDEPENDENT CONTRACTORS, AGENTS AND/OR EMPLOYEES OF THE FIX LLC.
Client Information
Name:
Home Address: City: State: Zip:
Cell phone: Business Telephone:
Date of Birth:
Age:
Sex: E-Mail Address:
Referral from: Member of Group:
If no referral or group, how did you hear about us:
List the medications you are now taking and the respective doses:
List any allergies you have to drugs, food or other items:
Are you currently under medical care for any reasons? If yes, please explain:
Primary Care Physician:
Name:
Address and City:
Phone:
Please check if you suffer from any of the conditions listed below:
High blood pressure
Kidney Disease
Joint or muscle injuries
Stroke:
Migraines
Areas of chronic pain
Joint Diseases
Respiratory Diseases
Areas of numbness
Paralysis
Tension headaches
Heart Disease
Diabetes
Skin Disease
Digestive Disease
Infectious Disease
Other serious illnesses or medical conditions (Please Explain):
THIS A LEGALLY BINDING RELEASE, WAIVER, INDEMNIFICATION OF LIABILITY, AND EXPRESS ASSUMPTION OF RISK. Read it carefully before signing.
- I hereby affirm that I have read this document in its entirety. I agree to each and every term and condition of this document.
- I hereby acknowledge and understand the inherent extreme risks in all physical conditioning and use of equipment related thereto including Wholebody Cryotherapy, Cryo Local, Cryo Facial, infrared sauna, massage therapy, cupping,acupuncture, feldenkrais, fascia blasting, Theragun use, Photobiomodulation(Laser therapy) , Celluma low lite therapy, dry brushing, personal training, , oxygen therapy, compression therapy, IV therapy and vitamin injections, VI Peels, Botox, Hydrafacial Elite, esthetician services and any other services and therapies we offer at The Fix ("Activities"). I also realize that risks may be caused by bad decision-making, inattention, actions or other participants, misuse or failure of equipment and freakish accidents that cannot be foreseen. I acknowledge that the above list is not inclusive of all possible risks associated with the Activities listed above, and I agree that said list is in no way limits the extent or reach of this release. I understand that the aforementioned hazards and risks are described by way of example only, and that there are numerous other hazards and risks inherent in all the the Activities to which I may be exposed. I VOLUNTARILY ASSUME ALL SUCH RISKS WITH THE FULL KNOWLEDGE AND APPRECIATION OF THE DANGER AND RISKS INVOLVED.
- I am unaware of any physical or mental condition that would (a) prevent me from safely participating in the Activities or (b) endanger my health or safety or the health and safety of others due to my participation in one or more Activities. I attest that I am physically fit and competent to participate in the Activities, and that all of my questions regarding the Activities have been answered to my satisfaction. I further attest that I am at least 18 years of age and otherwise legally competent to sign this document.
- I UNDERSTAND THAT THERE ARE DANGERS AND RISKS INHERENT IN THE ACTIVITIES, INCLUDING THE RISK OF SERIOUS PERSONAL INJURIES, PARALYSIS, AND DEATH.
- IN CONSIDERATION FOR MY BEING ALLOWED TO PARTICIPATE IN THE ACTIVITIES:
- I, on behalf of myself, my family, heirs, successors, assigns, and anyone claiming interest through me, hereby KNOWINGLY, INTENTIONALLY AND VOLUNTARILY WAIVE, RELEASE, INDEMNIFY AND AGREE TO HOLD HARMLESS THE FIX LLC, all landowners and/or agencies on whose property (owned, leased or otherwise) the Activities take place, and all sponsors, and all members, managers, officers, directors, employees, independent contractors, volunteers, agents, successors, assigns and representatives of TAOF (collectively referred to as the “Released Parties”) FROM ANY AND ALL ACTIONS, SUITS, CLAIMS, DAMAGES, AND LIABILITY (INCLUDING ATTORNEY FEES AND COSTS), THAT I, my family, heirs, successors, assigns, and anyone claiming any interest through me, MAY HAVE FOR ANY DAMAGE, INJURY, PARALYSIS, LOSS, OR DEATH TO MYSELF OR ANY OTHER PERSON OR PROPERTY ARISING OUT OF MY PARTICIPATION IN THE ACTIVITIES, whether such damage, injury, paralysis, loss, or death results from NEGLIGENCE or any act or omission of any of the Released Parties or from some other cause. I understand and explicitly agree that neither I, my family, heirs, successors, assigns, or anyone claiming any interest through me, will bring any legal action whatsoever against any of the Released Parties as a result of any such damage, injury, paralysis, loss, or death to myself or any other person or property that arises out of my participation of the Activities.
- I understand and agree that none of the Released Parties may be held liable or responsible in any way to me or my family, heirs successors, assigns, or anyone claiming any interest through me, for any injury, death, or other damages that may occur as a result of my participation in the Activities or as a result of any participant or party, including the Released Parties, whether passive or active.
- I hereby personally assume all risks, whether foreseen or unforeseen, in connection with the Activities, for any harm, injury or damage that may befall me while I participate in an activity, including the risk of negligence of any party or participant, including the Released Parties.
- I understand that my participation in the Activities may be photographed and promoted by THE FIX LLC and the organizers and sponsors of the Activities. In consideration for permission to participate in the Activities, I hereby give the absolute right and permission to THE FIX LLC, its agents, licensees, successors and assigns to use my likeness for any purpose whatsoever, including, but not limited to, to publish, broadcast, and copyright my voice and video recording, name, picture, and likeness, or any material based upon or derived therefrom created by THE FIX LLC is owned by THE FIX LLC. If I should receive any print, negative, or other copy, I shall not authorize its use by anyone else. I shall have no right of approval, no claim to additional compensation, and no claim (including, without limitation, claims based upon invasion of privacy, defamation, or right of publicity) arising out of any such use, alteration, distortion, or illusionary effect or other use in any composite form. I agree that this release does not in any way conflict with any existing commitment on my part.
Whole Body Cryotherapy
THERAPY WAIVER, RELEASE AND CONSENT FORM
In the event I participate in cryotherapy, I acknowledge and agree that the following additional terms and conditions apply:
Whole Body Cryotherapy
Whole body cyotherapy is the exposure of a person’s skin to temperatures of -150 to - 170 degrees Celsius (- 238 to – 274 degrees Fahrenheit) for a short time (3 minutes or less). At this extreme temperature, the body activates several mechanisms that have significant long-term medical and cosmetic benefits:
Skin:
The outer skin is briefly ‘frozen’, activating increased production of collagen in deeper layers of the skin (similar to lasers treatments of the face, where very hot 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.
Endocrine:
The extreme cold exposure causes to the body to turn up its metabolic rate in order to produce heat. This effect lasts for 5 -8 hours after the procedure, causing the body to ‘burn’ 500 – 800 Kcal over the hours following the procedure. After several procedures, the increase in metabolic rate tends to last longer between treatments. Another ‘survival reaction’ to the extreme temperatures is the release of endorphins (hormones) that have analgesic and anti-inflammatory properties, and improve mood disorders. Cryotherapy has been studied for the successful treatment of medication resistant depressive disorders.
Patients furthermore experience a noticeable increase in libido, lending to the use of cryotherapy for ED and other sexual disorders.
Musculoskeletal:
The anti-inflammatory and analgesic properties of cryotherapy can drastically improve joint disorders such as rheumatoid- and osteoarthritis. Athletes are using whole body cryotherapy to recover from injuries and improve their performance.
Immune System:
Cryotherapy may improve the function of the immune system and decrease stress levels.
Local Cryotherapy
Our facility uses a liquid nitrogen-cooled device to treat shoulders, back, arms, wrists, legs, and ankles. The rapid cooling of the device operating at -160 degrees Celsius causes fast relief of pain and decreases inflammation, speeding up the healing process. Treatments last three to five minutes.
Cryofacial©
Local application of pressurized nitrogen vapors to the skin of the face and neck. The application stimulates the production of collagen and decreases pore size of the skin. Over time, skin becomes more elastic and even-toned.
Safety Instructions for Whole Body Cryotherapy:
- You must wear cotton or wool socks (and underwear in men) 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;
- During treatment, you must keep your hands visible to the operator at the upper rim of the cryocabin as instructed;
- 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 foods, cosmetics, or medication, including but not limited to the following: Tranquilizers, High blood pressure medication;
- A person who is less than (18) years of age may not use whole body cryotherapy without parental consent;
- No metal, no plastic or moisture on your body during the treatment.
Initials:
Contraindications to using Whole Body Cryotherapy:
Pregnancy, severe 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, Raynaud’s Syndrome, 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.
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.
WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT
WITH RESPECT TO CRYOTHERAPY
- In consideration for using the cryo device (Equipment), I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS Cryousa, LLC, its officers, servants, agents, employees and volunteers and THE FIX LLC, its managers, members, officers, servants, agents, employees and independent contractors (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.
- 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 CONSENT is being given in advance of any administration of the process, and is being given by me voluntarily to use the Equipment and receive cryotherapy.
- I am fully aware of the risks and hazards connected with the use of the Equipment and cryotherapy, including the risk of physical injury or disability as the result of such injury, and I am voluntarily participating in said Equipment usage and therapy, 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 and the therapy by me.
- 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, 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 COLORADO.
- I understand that the RELEASEES will not be responsible for any medical costs associated with any injury.
- I understand that 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.
- I understand that Whole Body Cryotherapy therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe, are not medical professionals and that nothing said in the course of the session should be construed as such.
- 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 neglect to do so.
GENERALLY APPLICABLE TERMS AND CONDITIONS
By signing this document, it is my intent to personally accept full responsibility for and assume all risk of injury or death. I understand and agree that THE FIX LLC will not provide any insurance, or benefits, including workman’s compensation benefits, on behalf of any participant in the Activities. I understand that the terms of this document are contractual and not a mere recital and state that I have signed this document voluntarily and of my own free will.
This document shall be governed by interpreted under the law of Colorado, without regard to conflict of laws provisions. If any lawsuit or claim is brought regarding of my participation in the Activities, I agree that jurisdiction and venue for such suit shall be in the state courts located in Pitkin County, Colorado, and hereby irrevocably waive any other jurisdiction or venue to which I or my estate might otherwise be entitled. If any provision of this Agreement is or becomes invalid or unenforceable in whole or in part, such provision shall be deemed amended to conform to the requirements of the law so as to be valid and enforceable, or if it cannot be amended without materially altering the intention of the parties, it shall be stricken and the remainder of the Agreement shall remain in full force and effect. I HEREBY WAIVE MY RIGHT TO HAVE ANY DISPUTE OR CLAIM ARISING FROM MY PARTICIPATION IN ANY OF THE ACTIVITIES TRIED TO A JURY.
I have read this document in its entirety and I understand this liability release and express assumption of risk, and sign this document on behalf of myself and my heirs to evidence my agreement to each and every term and condition.
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 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 and receive therapy 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 facilities.
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; 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.
CANCELLATION POLICY
I understand that if I must cancel a scheduled appointment, I must notify at least 48 hours in advance or I will be held responsible for payment in full. I understand that my credit card will be automatically charged.
Initial: