PLEASE READ CAREFULLY BEFORE SIGNING Contraindications: Do not use Whole Body Cryotherapy if you have any of the following conditions: - Uncontrolled high blood pressure
- Prior heart attack
- Unstable chest pain
- Disease of blood vessels
- History of blood clots
- Uncontrolled Seizure Disorder
- Cold Allergy
- Open sores
- Nerve pain in feet or legs
- Pregnancy
- Raynaud’s Disease
- Conditions or Disease with Increased Sensitivity to Cold
You may have other conditions that make whole body cryotherapy inappropriate. Consult with your doctor or medical advisor if you have questions as to whether whole body cryotherapy is right for you. BY SIGNING BELOW YOU CONFIRM TO [NAME OF ENTITY] (THE “COMPANY”) FOR THE BENEFIT OF THE RELEASED PARTIES (AS LATER DEFINED) THAT YOU HAVE CAREFULLY READ BOTH PAGES OF THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS, VOLUNTARILY AGREE TO EACH OF ITS TERMS AND PROVISIONS, AND SIGN OF YOUR OWN FREE WILL.
Agreements: - Follow all instructions given to you by the attendant. Do not use whole body cryotherapy without an attendant present.
- Participation in a whole body cryotherapy session involves exposure to extreme cold temperature for a short period of time (not to exceed three (3) minutes per session). Your clothing and skin must be dry. You must wait 20 min after exercise before entering the chamber. You must avoid inhaling the nitrogen gas that is emitted into the equipment. No minors under the age of 16 can enter the chamber. By signing this Agreement you confirm that you are in good health and do not have any of the contraindications identified above or other physical condition that would preclude you from safely using whole body cryotherapy.
- If you experience any pain or mental or physical discomfort at any time during the process, you may terminate the session immediately. The chamber will not be locked, and you are free to walk out of the chamber at any time. You agree that you have familiarized yourself with this exit process and are prepared to do so if or when you feel it is necessary.
- No representations or claims are made as to the medical benefits of whole body cryotherapy, including without limitation claims that whole body cryotherapy reduces muscle soreness, or promotes mechanisms of action such as increased blood circulation, capillary action, or rapid cooling of the skin, tissues or muscles. Whole body cryotherapy is not intended to diagnose, treat, cure or prevent diseases, illnesses, imbalances or disorders. No results from whole body cryotherapy are assured. Every customer is different and responds differently to the therapy.
Waiver and Release: - This is a release of liability and a waiver of certain legal rights.
- By signing this Agreement you:
- a. acknowledge that use of whole body cryotherapy involves risk of bodily injury, illness, disability or death, which may be compounded by negligent emergency response of the attendant or inadequate ventilation of the room in which the equipment is operated. You acknowledge that you are voluntarily participating in whole body cryotherapy with knowledge of the dangers involved and accept and assume all risks of injury, illness, disability or death, whether caused by the condition of the facilities or equipment or the negligence of the attendant or otherwise. You acknowledge that frostbite is a specific risk that you assume.
- b. expressly waive and release any and all claims against Company, Impact Cryotherapy, Inc., and their respective officers, directors, employees, agents, affiliates, successors and assigns (which are collectively referred to as “the Released Parties”), arising out of or attributable to your use of whole body cryotherapy. You covenant not to assert any such claims against the Released Parties, and forever release and discharge the Released Parties from liability for such claims.
- c. indemnify and hold harmless the Released Parties from any loss, liability, damage, cost or expense arising out of or connected in any manner with your use of whole body cryotherapy.
- d. agree that this waiver and release is intended to be as broad and inclusive as permitted under law. You specifically acknowledge and agree that this Agreement is not intended to be a general release subject to limitations and conditions that would otherwise apply under applicable state law and additionally agree to waive all general release limitations provided by applicable law.
General Provisions: - This Agreement shall be construed and interpreted as broadly as possible under the applicable law of the jurisdiction in which you use whole body cryotherapy, with the words, terms, provisions, covenants, and remedies contained in this Agreement to be enforceable to the fullest extent permitted by applicable law.
- If any portion of this Agreement is held invalid, the remainder shall not be affected and shall continue in full legal force and effect.
- The terms of this Agreement shall continue from this date forever and shall apply to each use by you of whole body cryotherapy without the need for you to re-execute this Agreement.
- This document constitutes the entire agreement regarding your use of whole body cryotherapy and any product, services or equipment connected with the Released Parties and supersedes all prior discussions, agreements and representations about the use, benefits or risks of whole body cryotherapy. This Agreement may only be modified in a writing signed by you and an authorized representative of the Company.
Dated: November 21, 2024
NormaTec Waiver of Liability, Release and Hold Harmless Agreement In consideration for using the NormaTec Recovery System I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS 509Cryo LLC, its owner and employees 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. Contraindications: Do not use NormaTec® Compression Therapy if you have any of the following conditions: - Current or unstable fractures/breaks
- Recent surgery and have sutures/stitches
- Open wounds, contusions, abrasions
- Suspect or known Acute deep vein thrombosis (DVT) (blood clot)
- Severe atherosclerosis (disease of the arteries)/Ischemic vascular disease (IVD)
- Severe congestive cardiac failure (CHF)
- Existing pulmonary edema (having excess fluid in the lungs)
- Existing pulmonary embolism (blood clot in the lungs)
- Extreme deformity of the limbs
- Any local skin conditions such as gangrene, untreated or infected wounds, recent skin graft, or dermatitis
- Known presence of malignancy in the legs or arms
- Limb infections, including cellulitis that have not been treated
- Presence of Lymphangiosarcoma (a rare cancer due to long-standing lymphedema of the upper/lower extremities)
Patient’s Consent: My signature constitutes my acknowledgment that (A) I have read, understand, and fully agree to the foregoing CONSENT, (B) the proposed usage of the NormaTec equipment has been satisfactorily explained to me and I have all of the information I desire and (C), I hereby give my authorization and consent. This CONSENT shall stand as long as I use the NormaTec equipment at 509Cryo LLC 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 509Cryo LLC from any damage or harm that I might incur due to use of the NormaTec equipment. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read and understand the foregoing Waiver of Liability, release and Hold Harmless Agreement, I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same. Furthermore, I agree that I will comply with all instructions on the use of the Equipment and that I am using these services at my own risk. DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM. You have the right to withdraw consent for this procedure at any time before it is performed.
|
