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CRYOTHERAPY WAIVER AND CONSENT FORM

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 eventoned, 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 antiinflammatory 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 improves the function of the immune system and decreases stress levels.   

 Safety Instructions for Whole Body Cryotherapy: 

  1.  You must wear cotton or wool socks (and underwear in men) to avoid chilblain.
  2.  Treatments are limited to 3 minutes per session. Overexposure 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.  You may end the procedure at any time if you experience any problems or anxiety; 
  5. 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;
  6.  A person who is less than (18) years of age may not use whole body cryotherapy without parental consent;
  7.  Children under the age of 14 are prohibited from the cryotherapy due to the inability to regulate body temperature.  

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.  

In Consideration for using the cryo device (the equipment) I hereby EXPRESSLY RELEASE, WAIVE, DISCHARGE AND HOLD C4 Cryo, LLC, ITS MEMBERS, OWNERS, OFFICERS, REPRESENTATIVES, AGENTS, EMPLOYEES, CONTRACTORS, ASSIGNEES AND VOLUNTEERS (HEREINAFTER REFERRED TO AS THE "RELEASEES"), FROM ANY AND ALL CLAIMS (INCLUDING, BUT NOT LIMITED TO, CLAIMS FOR PROPERTY DAMAGE, PERSONAL INJURY OR DEATH), LIABILITY, DEMANDS, ACTIONS AND CAUSES OF THE ACTION WHATSOEVER, WHETHER FORESEEABLEOR NOT, FOR NEGLIGENCE, CARELESSNESS AND STRICT LIABILITY OR OTHERWISE (INCLUDING, BUT NOT LIMITED TO, AND NEGLIGENCE OF THE RELEASEES), 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 and agree that the RELEASES HAVE NOT MADE AND DO NOT HEREBY MAKE, NOR SHALL THIS WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT (THIS "AGREEMENT") NOR THE CRYO PROCESS TO BE PERFORMED BY THE RELEASEES UNDER THIS AGREEMENT GIVE RISE TO AND REPRESENTATIONS, WARRANTIES, OR COVENANTS (EXPRESS, IMPLIED, ORAL OR OTHERWISE), INCLUDING, WITHOUT LIMITATION, ANY IMPLIED WARRENTY OF THE MERCHANTABILITY, WORKMANSHIP OR FITNESS FOR A PURPOSE WITH RESPECT TO THE CRYO PROCESS. I UNEQUIVOCALLY REPRESENT, ACKNOWLEDGE AND STATE THAT IN EXECUTING AND DELIVERING THIS AGREEMENT, I AM NOT RELYING UPON ANY WARRENTIES, REPRESENTATIONS, PROMISES OR STATEMENTS, WHETHER EXPRESS OR IMPLIED, MADE BY RELEASES, AND AM RELYING SOLELY ON MY OWN INSPECTION, INVESTIGATION, AND JUDGMENT. I fully understand the administration of the process, including possible adverse reactions, side effects or the other possible complications. It is understood that this Agreement is being given in advance of ant 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 with the use of the Equipment, including the risk of physical injury or disability as the result of 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 as a result of being engaged un such activity.

I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS THE RELEASEES FROM AND AGAINST ALL RISKS ABD CLAIMS OF ANY NATURE FOR ANY LOSS, DAMAGE OR COSTS THAT I MAY INCUR DUE TO THE USE OF THE EQUIPMENT BY ME, SPECIFICALLY INCLUDING, BUT NOT LIMITED TO, NEGLIGENT ACTS BY MYSELF OR OTHERS.

It is my express intent that this Agreement shall bind the members of my family and my 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 Agreement shall be construed in accordance with the laws of the State of TEXAS.

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 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 forget to do so.

My signature below constitutes my acknowledgement that (1) I have carefully read this entire Agreement and fully understand and agree to be bound by its contents, (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 Agreement 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 RELEASEES, owners, operators, franchisers, or manufacturers, from any damage or harm that I might incur do to use of the facilities.

IN SIGNING THIS AGREEMENT, I ACKNOWLEDGE AND REPRESENT THAT I am at least eighteen (18) years of age and legally competent; I HAVE GIVEN UP CONSIDERABLE FUTURE LEGAL RIGHTS; AND I EXECUTE THIS AGREEMENT FREELY, VOLUNTARILY, UNDER NO DURESS OF 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 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.

CONTRAINDICATIONS TO USING WHOLE BODY CRYOTHERAPY:

Pregnancy, severe Hypertension (BP > 160/100), acute or recent myocardial infarction, unstable angina pectoris, arrhythmia, symptomatic cardiovascular disease, cardiac pacemaker, stroke, 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 of age (parental consent to treatment needed), acute kidney and urinary tract diseases. 

I have read and confirm I do NOT have, or have had, any of the contraindications above.

 

Dated: August 18, 2018

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Participant'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's Email Address

Email*

Confirm Email*
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Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
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's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Height: *

Weight: *

Referral from:

If no referral, how did you hear about us:

List the medications you are now taking, the condition associated with it, and the respective doses:

List and allergies you have to drugs, food, or other items:

Are you currently under medical care for any reasons? If yes, please explain:
Please check if you have, or have had, any of the conditions listed below:
High Blood Pressure
Joint Disease Diabetes
Kidney Disease
Tension Headaches
Infectious Disease
Joint and Muscle Injuries
Skin Disease
Paralysis
Stroke
Respiratory Disease
Pregnancy
Migraines
Heart Disease
Areas of Numbness
Areas of Chronic Pain
Cancer
Other

If yes, please explain:

NOTE: Upon any change in medical history and/or medications, the client is responsible to report details to staff to ensure client safety.   

Parent or Guardian's 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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