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Waiver & Consent Form

Cryotherapy is a hyper-cooling process in which the body is exposed to very cold temperatures in order to aid athletic performance and recovery, inflammation and pain reduction, and other health and wellness goals by stimulating the body's natural healing process. We offer whole body cryotherapy (WBC), localized cryotherapy and a cryotherapy facial.

Safety Instructions for cryotherapy that must be followed at all times:

During WBC, You must wear DRY cotton or wool socks, DRY cotton or wool gloves, DRY underwear (men) and protective shoes. We provide this for you. 
Sessions are limited to a maximum of 3 minutes. Overexposure to cold could cause chillblain.
During sessions, you must avoid inhaling the nitrogen fumes. While non-toxic, they are devoid of oxygen and may cause fainting.
Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, lotions, ointments, medications or chemicals, including but not limited to: tranquilizers, high blood pressure medication
All jewelry must be removed prior to your session. We recommend makeup be removed prior to a cryotherapy facial.
A person who is less than 18 years of age may not use cryotherapy without parental consent. We require you to be at least 13 years of age to participate in whole body cryotherapy. There is no age requirement for localized cryotherapy.
You may end the procedure at any time if you experience any problems or anxiety.

ABSOLUTE CONTRAINDICATIONS TO WHOLE BODY CRYOTHERAPY:

Pregnancy, severe Hypertension (BP> 180/100), acute or recent myocardial infarction (heart attack), unstable angina pectoris (chest pain), arrhythmia, valvular or ischemic heart disease,symptomatic cardiovascular disease, cardiac pacemaker, stent, peripheral arterial occlusive disease, venous thrombosis or blood clots, acute or recent cerebrovascular accident (stroke), uncontrolled seizures, unmanaged diabetes, hyperhidrosis, Raynauds Syndrome, fever, tumor disease, symptomatic lung disorders, bleeding disorders, severe anemia, infection, cold allergy, acute kidney and urinary tract diseases.

POSSIBLE RISKS OF CRYOTHERAPY:

Fluctuations in blood pressure during the procedure by up to 10 points systolically (this effect reverses after the end of the procedure, as peripheral circulation returns to normal), allergic reaction to extreme cold (rare) or other adverse skin reaction, claustrophobia, anxiety, fainting, activation of some viral conditions (cold sores) etc. due to stimulation of the immune system.

ABSOLUTE CONTRAINDICATIONS TO CRYOSKIN TONING AND SLIMMING:

SEVERE RAYNAUD'S SYNDROME, SEVERE ALLERGY TO THE COLD, AND PROGRESSIVE DISEASES (MS, ALS, PARKINSON'S, NEUROPATHY) ACTIVE CANCER, PREGNANCY (ONLY THE FACIAL MAY BE DONE), LYMPHATIC DISORDERS, SEVERE KIDNEY AND LIVER DISEASES AND SEVERE DIABETES.

ABSOLUTE CONTRAINDICATIONS TO CRYOSKIN FACIALS:

BOTOX IN THE LAST 30 DAYS
FILLERS IN THE LAST 60 DAYS 
THREADING IN THE LAST 90 DAYS

By initialling below I acknowledge the list of contraindications and certify that none of the above applies to me.

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT:

In consideration for using the cryosauna, fitness equipment and receiving cryotherapy related services (Equipment), I hereby RELEASE, WAIVE, DISCHARGE IN ADVANCE, and HOLD HARMLESS Excel Cryotherapy, LLC , its dbas, officers, servants, officials, employees, agents, franchisees and volunteers (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 me, 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.

I am fully aware of the risks and hazards connected to the use of the equipment, including the risk of physical injury, death or disability as a 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 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 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 the equipment by me. I understand that the RELEASEES will not be responsible for any medical costs associated with any injury.

It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family, spouse, heirs, assignees, and personal representatives 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 NEW MEXICO.

I understand that Cryotherapy and the equipment is provided for the basic purpose of therapeutic recovery only by persons in good general health. I further understand that Cryotherapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a medical doctor, physician, chiropractor or other qualified medical professional for any ailment I am aware of and should seek their counsel as to my physical readiness and for permission to use Cryotherapy. If I should faint due to excess nitrogen inhalation, I hold myself responsible for all injuries should I fall, and the cryosauna attendant has the right to assist me.

I understand that  Cryotherapy attendants are not qualified to diagnose and/or prescribe and that nothing said in course of 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 attendant updated as to any changes in my health or medical profile and understand there should be no liability on the attendants part should I forget to do so.

Photos: I understand that I may be asked to have my picture taken and/or provide a video testimonial. I understand it is my right to decline this and should I decline this, my photo and/or video testimonial will not be taken. Should I grant permission for my photo and/or video testimonial to be taken, I give permission for images of me and my likeness to be used solely for the purposes of Excel Cryotherapy LLC for promotional, marketing, advertising, and other similar activities. I understand no compensation will be offered for use of my photo and/or video testimonial.

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 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 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, and I execute this Release freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me 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. 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.

By signing below, I affirm that I have read and fully understand the risks as outlined in this waiver and agree to all terms.

 

Please select who will be participating...
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First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Height*
First Client's Signature*
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional information

Were you referred by someone? If so, whom?
Do you wish to receive appointment reminders via text?*
No
Yes

If you wish to receive texts, who is your cell phone provider?
Do you currently have a fever?*
No
Yes
Are you pregnant?*
No
Yes
Please check if you have ever or currently suffer from any of the following conditions:
Allergy to Cold Temperatures
Areas of chronic pain
Arrhythmia
Asthma
Bleeding Disorder
Cardiovascular Disease
Claustrophobia
COPD
Deep Vein Thrombosis (DVT)
Diabetes
Epilepsy or Seizure Disorder
Fainting Spells
Headaches/Migraines
Heart Attack
Heart Disease
Heart Disorders
Heart Surgery/Stent
High Blood Pressure/Hypertension
Hyperhidrosis
Joint Disease
Joint or muscle injuries
Kidney Disease/Infection
Lung Disorder
Pacemaker
Paralysis
Peripheral Arterial Occlusive Disease
Raynaud's Syndrome
Respiratory Disease
Severe Anemia
Skin Disease/Infection
Stroke
Tumor Disease
Unstable Angina Pectoris
Urinary Tract Disease/Infection

Please list any other illnesses, disorders, conditions or injuries:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian Date of Birth*
Parent or Guardian Information
Height*
Parent or Guardian Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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