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CONFIDENTIAL

Whole Body Cryotherapy

THERAPY WAIVER AND CONSENT FORM

Whole Body Cryotherapy

Whole body Cryotherapy is the exposure of a person’s skin to temperatures of -110 to -180 degrees Celsius (-166 to - 292 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 laser 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 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 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 the body to turn up its metabolic rate in order to produce heat. This effect lasts for a few hours after the procedure, causing the body to ‘burn’ 500-800 calories over the hours following the procedure. After several procedures, the increase in metabolic rate tends to last longer between treatments. Another ‘survival reaction’ for 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 successful treatment of medication resistant depressive disorders. Patients furthermore experience and 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 osteoarthritis. Athletes are using whole body cryotherapy to recover from injuries and improve 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, slippers and gloves (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 and problems or anxiety.
  5. Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, or medication, included but not limited to the following: Tranquilizers, High blood pressure medications
  6. A person who is less than (12) years of age may not use whole body cryotherapy and a person who is less than (18) years of age may not use whole body cryotherapy without parental consent.

Contraindications to using Whole Body Cryotherapy:

Pregnancy, severe Hypertension (BP>180/100), acute or recent myocardial infarction, unstable angina pectoris, arrhythmia, 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, anemia, infection, claustrophobia, cold allergy, age less than 12-18 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 systolic 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

In consideration for using the cryo device (Equipment), I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS 19​ th​ Hole Enterprise LLC.​, its officers, servants, agents, employees, 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 any person, while using the equipment or due to the use of 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 that 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 with the use of the equipment, including the risk of physical injury or disability as the result of such injury, and I am voluntarily participating in said equipment usage, and entering the above named precisely 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 by me. It is in 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 Arkansas.

I understand that the RELEASEES will not be responsible for any medical costs associated with the 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 specialists for any mental or physical ailment 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 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 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 the 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.

Date: July 16, 2025

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also 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*
Date of Birth
Parent or Guardian's Information
Referral from:
Gender:*
Females: Are you pregnant?
If no referral, how did you hear about us:

Please indicate your interest in the following benefits of whole body cryotherapy
(1 indicates little interest, 5 indicates great interest):

Tension release:*
Relaxing Treatment:*
Relief of pain or stiffness:*
Improvement of athletic performance:*
Recovery from injury, illness or surgery:*
Please check if you suffer from any of the conditions listed below:
High Blood Pressure
Digestive Diseases
Skin Disease
Stroke
Migraines
Joint or muscle injuries
Heart Disease
Kidney Disease
Infectious Disease
Areas of numbness
Tension Headaches
Areas of Chronic Pain
Respiratory Diseases
Joint Disease
Infection of any sort
Paralysis
Diabetes
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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