Safety Instructions and Contraindications for all Treatments
The following waiver, initialed areas and signatures constitute my representation, acknowledgement and agreement that I, , have read, understand, and fully agree to the following:
Mandatory Safety Instruction for Whole Body Cryotherapy (WBC)
1. You must wear cotton or wool socks (and underwear for men) to minimize the potential of chilblain and other potential injuries from overexposure to cold temperatures
2. Sessions are limited to 3 minutes per session to minimize the potential for such adverse effects from overexposure to cold temperatures.
3. During the session, you must ensure that your head remains above the level of, and avoid inhaling, gasiform air (the cloudy gas circulating in the cryochamber) while non-toxic, it is devoid of oxygen and may cause shortness of breath, fainting, or other conditions.
4. You must immediately notify the attendant and end the session if you at any time experience any physical or mental discomfort, problems, pain or anxiety
5. Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, lotions, piercings, or medication, including but not limited to, tranquilizers and high blood pressure medication do not use WBC if you have reason to believe you have come in contact with or ingested any such product.
6. A person who is less than (18) years of age may not use the WBC without written parental consent
7. A person who is less than (12) years of age may not use the WBC even with parental consent
Whole Body Cryotherapy Contraindications
Do not use WBC if you have or may have any of the following conditions: pregnancy, stage 2 Hypertension (BP greater than 160/100) according to the American Heart Association, acute or recent myocardial infarction, unstable angina pectoris, arrhythmia, symptomatic cardiovascular disease, 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 needed) acute kidney and urinary tract diseases. If you have any other injury, illness or medical condition, you should consult with your physician prior to using cryotherapy.
Risks of WBC include, but are not limited to: fluctuations in blood pressure (due to peripheral vasoconstriction, systolic blood pressure may briefly increase by up to 10 points during session. This effect should reverse after the end of the session, 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. One primary inherent risk of cryotherapy is skin sensitivity and skin irritation. It is impossible to predict how client’s skin will react during or after cryotherapy.
Spot (local & facial) Cryotherapy Contraindications
Do not use spot 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 2, Raynaud’s Disease, severe sensory disorders, hypersensitivity to cold. If you have any other injury, illness or medical condition, you should consult your physician prior to using spot cryotherapy.
Do not use CryoSkin if you have or may have of the following conditions: Severe Raynaud’s Syndrome, Suffer from very poor circulation, pregnant, Severe Diabetes, Cancer, Cosmetic filler within the last 3 months of your treatment. If you have any other illness or medical condition, you should consult your physician prior to using CryoSkin.
THOR Laser/ NovoTHOR Bed Contraindications
Do not use Thor if you have or may have any of the following conditions: Pregnancy, epilepsy, known carcinoma, have any photosensitivity or on any photosensitizing drugs. If you have any other illness or medical condition, consult your physician prior to using Thor.
THOR LX2 Laser/NovoTHOR Bed Session Consent
I understand that Thor LX2 is a laser and the Novathor Bed is a light therapy modality, intended to stimulate healing and relieve pain.
The session should not be painful and you should feel no significant heat but you may feel a pleasant warmth.If uncomfortable for any reason the client or therapist may ask to end the session, and the session will be ended immediately.
IV Therapy & Booster Shots
I have informed the qualified staff members of any known allergies to drugs or other substances, or of any past reactions to anesthetics. I have informed the qualified staff members of all current medications and supplements.
I understand that:
- The procedure involves inserting a needle into a vein and injecting the prescribed solution intravenously.
- Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.
- Risks of intravenous therapy include but not limited to:
o Occasionally to commonly - Discomfort, bruising, pain at the site of injection.
o Rarely - inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
o Extremely Rarely - Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.
I understand that Torodol is administered in some of the IV’s. I have been made aware that Torodol can affect a person with kidney issues and have informed the nurse if I have a kidney issue.
I understand that a lactated ringer is used in some of the IV’s. I have been made aware that a lactated ringer IV solution can affect a person with severe liver issues and have informed the nurse if I have a liver issue.
I understand that the B-12 intra-muscular shot can cause soreness and bruising in the arm and/or muscle.
Sculpsure Body and SculpSure Submental Treatment
- Skin may be slightly pink to red immediately after treatment and could last up to a few days.
- After treatment there may be swelling and tenderness that lasts approx. 2-3 (two to three) weeks, but may last longer. You may also experience tissue firmness or nodules. Nodules can last for days to several months, depending on the size of the nodule. This side effect typically resolves on its own. While uncommon, some nodules may be permanent.
- I understand that the practice of medicine is not an exact science and no results have been guaranteed. I acknowledge that the results may not meet my expectations. I certify that no guarantees have been made by anyone regarding the procedure(s) that I have requested and authorized
Normatec Pulse Technology Contraindications
Do not use Normatec if you have or may have any of the following conditions: current or unstable fractures or breaks, recent surgery and have stitches or sutures, open wounds, contusions, or abrasions. If you have any other injury, illness or medical condition, you should consult your physician prior to using Normatec.
Procell MD Microchanneling
POSSIBLE RISKS AND SIDE EFFECTS ASSOCIATED WITH MICROCHANNELING
• CONTRAINDICATIONS: Any condition that seriously impairs your immune system, active radiation or chemotherapy, pregnant or nursing, uncontrolled diabetes, allergy to stainless steel, chronic inflammatory skin disease, Accutane in the past 2 years, hemophilia or similar bleeding disorder
• I understand that Microchanneling is non-ablative skin rejuvenation & involves the creation of perforations in my skin to promote healing responses to rejuvenate my skin. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection & scarring. These effects have been fully explained to me.
Possible Risk: The risks of having blood drawn from your arm include some pain when the needle goes in and a small risk of bruising and/or infection at that site. Some people get lightheaded, nauseous, or faint. You are less likely to have these problems if you drink at least 2 glasses of water and have a snack before the blood draw.
Platelet Rich Plasma (PRP) Therapy
No guarantee or assurance was made, as to the results that may be obtained from the procedure/treatment. Specifically the risks were identified including but are not limited to the following:
• Increased pain and allergic reaction from local anesthetics, iodine, contrast (X-Ray dye), materials containing latex, IV anesthetics and/or other medications
• Infection on skin, tissue, bones, joints, discs, nerves, ligaments, possibly blood stream (Sepsis), brain and spinal cord (Meningitis) may require hospitalization
• Bleeding into epidural space (Epidural Hematoma) and into spinal canal (Spinal Hematoma) may require surgical interventions such as an evacuation of blood from epidural space, spinal canal and decompression surgery, blood vessel injury
• Nerve damage, tissue injury, tissue damage, temporary and permanent numbness and/or weakness, paralysis, spinal cord injury, urinary and/or fecal incontinence
• Headache (“Spinal headache”) may require blood patch (Injecting your own blood into epidural space) and hospitalization
• Joint injection: In addition to the above complications, injection and fluid collection in the joint(s) may require antibiotic treatment, fluid aspiration and surgical interventions.
• Allergic reaction from steroid; facial flushing, elevation in blood glucose, headache, increased appetite, weight gain, swelling, menstrual irregularities, hoarseness, numbness, infection, abnormal heartbeats, increased blood pressure, stroke, heart attack, insomnia, etc.
Waiver of Liability, Assumption of Risk and Hold Harmless Agreement
I, , in consideration for using and as a condition of my use of any equipment, product or service including, but not limited to, cryotherapy, local/facial cryotherapy, Normatec, Thor Laser, Novothor Bed, SculpSure, CryoSkin, Squid, Massage, Acupuncture, Hydrafacial, Facials, Botox , VI Peels, Procell Microchanneling, Celluma Light, Biomat , Theragun, IV Therapy & Vitamin Boosters, , Oxygen Therapy, , blood draws, Platelet Rich Plasma (PRP) therapy and all products, equipment, and services referred collectively as “activities”, have voluntarily chosen to participate in such activities with full knowledge of the risks and hazards described in the safety instructions set forth above and the release set forth below. In consideration of my participation, I acknowledge and agree that the activities may be strenuous and/or present an inherent risk of personal injury and property damage. I am responsible for consulting with my physician and ensuring that I am medically fit prior to participating. I represent and warrant that I am medically fit, have no known or suspected health conditions, including but not limited to preexisting injuries, illness or pregnancy, that prohibit or limit my participation in any activity in any manner, and am not under the influence of alcohol or drugs. At all times during my participation I will properly utilize all recommended safety equipment and follow all recommended instructions and procedures pertaining to the activity. While equipment, instructions and procedures may reduce inherent risk of the activity, I understand that a substantial risk of personal injury or property damage remain, and therefore, agree as follows:
1. ON BEHALF OF MYSELF, MY SPOUSE, CHILDREN (INCLUDING ANY OF WHICH I AMGUARDIAN), HEIRS, PERSONAL REPRESENTATIVES, EXECUTORS AND ASSIGNS AND ANYONE CLAIMING BY OR THROUGH ME OR ANY OF THE FOREGOING (‘RELEASORS’), I HEREBY VOLUNTARILY AGREE TO RELEASE, WAIVE, DISCHARGE, HOLD HARMLESS, DEFEND AND INDEMNIFY THE CRYO ENTITIES AND THEIR RESPECTIVE PREDESSORS, SUCCESSORS, AFFILIATES, MEMBERS, OFFICERS, MANAGERS, DIRECTORS, OWNERS, SERVANTS, AGENTS, EMPLOYEES, INSURERS, ATTORNEYS AND VOLUNTEERS (HEREINAFTER REFERRED TO AS “RELEASEES’) FROM ANY AND ALL CLAIMS,DEMANDS, LIABILITIES, LOSSES, INJURIES, PERSONAL INJURIES, PROPERTY DAMAGE, WRONGFUL DEATH,LOSS OF SERVICES, DAMAGES, ACTIONS OR CAUSES OF ACTION,PRESENT OR FUTURE, WHATSOEVER ARISING OUT OF OR CONNECTED WITH THE ACTICITIES, EQUIPMENT, PRODUCTS OR SERVICES OWNED, OFFERED OR PROVIDED BY THE CRYO ENTITIES, AND ANY EQUIPMENT, MACHINERY AND/OR FACILITIES OF ANY OF THE RELEASEES, EVEN IF CAUSED IN A WHOLE OR IN PART BY THE NEGLIGENCE OF ANY OF THE RELEASEES. I HAVE READ, UNDERSTAND AND VOLUNTARILY SIGN THIS DOCUMENT (INCLUDING THE WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT SET FORTH ABOVE) AND KNOWINGLY WAIVE ANY RIGHTS AGAINST, AND RELEASE THE RELEASEES FROM, ANY SUCH CLAIMS, DEMANDS, INJURIES, PERSONAL INJURIES, PROPERTY DAMAGE, WRONGFUL DEATH, LOSS OF SERVICES, DAMAGES, ACTIONS AND CAUSES OF ACTION.IT IS MY EXPRESS INTENTION TO EXEMPT AND RELIEVE THE RELEASEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH.
2. I hereby confirm that no warranty or guarantee, or other assurance, has been made to me covering the results of any services, products or equipment offered by The Fix LLC or any of the RELEASEES 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. Ii 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 equipment and/or obtain services from The Fix LLC.
3. I am fully aware of the risks and hazards connected with the use of equipment and the services, including the risk of physical injury or disability as the result of such injury, and I am voluntarily participating in said equipment usage and the receipt of any services, and entering the above named premises and employees relating thereto. 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.
4. I understand that this document, including the Waiver of Liability and Hold Harmless Agreement, shall be construed in accordance with the laws of the State of COLORADO. If any provision of this document is held to be unenforceable, this document shall be considered divisible and such provision shall be deemed inoperative to the extent it is deemed unenforceable, and in all other respects this document shall remain in full force and effect; provided, however, that if any such provision may be made enforceable by limitation thereof, then such provision shall be deemed to be so limited and shall be enforceable to the maximum extent permitted by law.
5. I understand the RELEASEES will not be responsible for any medical costs associated with any injury.
6. I understand that Whole Body Cryotherapy is provided for the basic purpose of relaxation, stress reduction and relief. 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 or other qualified medical specialist for any mental or physical ailments.
7. I understand that Whole Body Cryotherapy technicians are not qualified to perform skeletal adjustments, and/or prescribe, 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 therapist updated as to any changes in my medical profile and understand that there shall be no liability on any RELEASEES’ part should I forget to do so.
8. I have read the instructions for proper use of facilities and equipment and do so at my own risk and hereby release the owners, operator, franchisers, manufacturers, employees, contractors from any and all damage or harm that I might incur due to use of the facilities and equipment.
My signature below constitutes my knowledge that (1) I have read, understand, and fully agree to all of the foregoing, (2) the proposed indoor cryo process and all activities 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 any equipment or obtain any products or services at any facility utilized by The Fix LLC.
IN SIGNING THIS DOCUMENT, I ACKNOWLEDGE AND REPRESENT THAT I HAVE READ AND UNDERSTAND THIS DOCUMENT, INCLUDING THE WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT, I AM AT LEAST (18) YEARS OF AGE AND FULLY COMPETENT; I HAVE GIVEN UP CONSIDERABLE FUTRE LEGAL RIGHTS; AND I EXECUTE THIS DOCUMENT 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 CRYO DEVICE AND ALL OTHER EQUIPMENT AND THAT I AM USING SUCH EQUIPMENT AND OBTAINING SERVICES AT MY OWN RISK, I AGREE TO USE ALL SESSIONS WITHIN THE TERMS OF THE CONTRACT DATES (6 months from purchase date) AND UNDERSTAND THAT REFUNDS ARE NOT GIVEN ON UNUSED PORTIONS OF PURCHASED PACKAGE.
Late Arrival, Cancellation and No Show Policies
All clients are asked to arrive at least 5 minutes before your scheduled appointment time. Therapist cannot go over the allotted time since most sessions are booked back to back. If a client is more than 10 minutes late for a 30 minute session OR 20 minutes late for a 60 minute session, the appointment is considered a “NO SHOW”.
All cancellations require 48 hour notice. Any cancellation made less than 48 hours from the session time will be charged the session rate. If a clients’ card is on file The Fix LLC has permission to charge card for service missed without client disputing. An exception will be made if there is a contagious illness, sudden emergency or inclement weather.
No Show Policy
If a client is a “No Show” an appointment will be considered a cancellation and be charged the session rate. If a clients’ card is on file The Fix has permission to charge card for service missed without client disputing. An exception will be made if there is a contagious illness, sudden emergency or inclement weather.
Participant’s Printed Name: