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CRYO252 Liability Waiver / Held Harmless Agreement

Safety Instructions for Whole Body Cryotherapy:

You must wear cotton or wool socks (and underwear for men) to avoid chilblain.

Treatments are limited to 3 minutes per session.  Overexposure to the cold temperatures may cause chilblain;

During treatment, you must avoid inhaling nitrogen fumes; while non-toxic, they are devoid of oxygen and may cause fainting;

During treatment, you must keep your hands visible to the operator at the upper rim of the cryochamber as instructed;

You may end the procedure at any time if you experience any problems or anxiety;

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;

A person who is less than (18) years of age may not use whole body cryotherapy without parental consent

It is important to not shave exposed areas within 8 hours of a session.

Contraindications to using Cryotherapy:

Pregnancy, severe Hypertension (BP>180/100), acute or recent myocardial infarction, unstable angina pectoris, arrhythmia, symptomatic cardiovascular disease, cardiac pacemaker, peripheral arterial disease, cold-activated asthma, venous thrombosis, acute or recent cerebrovascular accident, uncontrolled seizures, Raynaud’s Syndrome, fever, Cryoglobulinemia, Cryo briogenmua, Agammaglobulinemia, Active Cancer, DVT, Acute infections, Certain medications (antipsychotic, alcohol), Cold intolerance/allergy to cold, Damaged skin, Claustrophobia, symptomatic lung disorders, bleeding disorders, severe anemia, infection, age less than 18 (parent consent needed), acute kidney and urinary tract diseases.

Precautions

Heart valve malfunction, Arrhythmia, Angina, A history of vein thrombosis and clotting, excessive sweating

Risks of whole body cryotherapy/local cryotherapy:

Fluctuations in blood pressure (whole body cryotherapy only, due to peripheral vasoconstriction, blood pressure may increase by up to 10 points systolically during treatment), allergic reaction to extreme cold (rare), anxiety, temporary redness of the skin, chilblain/skin burns/scarring (very rare).

Waiver of Liability and Hold Harmless Agreement:

In consideration for using cryotherapy treatments/machines (equipment), I hereby release, waive, discharge, and hold harmless CRYO252, its officers, servants, agents, employees and volunteers (hereinafter referred to as releases) from any 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 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 cryotherapy treatments, 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 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 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 an activity. I further hereby agree to indemnify and hold harmless the releases from any loss, liability, damage or costs that may incur due to the use of equipment by me.

It is my express intent that this release and hold harmless agreement shall bind the members of my family and spouse if I am alive, and my heirs, assigns and personal representatives, if I am not alive, and shall be deemed as a release, waiver, and discharge of the above named releases.  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 North Carolina.

I understand that the releases will not be responsible for any medical costs associated with any injury.

I understand that the equipment is designed for fitness and appearance enhancing use only by persons in good health.  I have been advised that if I suffer from any medical condition or illness whatsoever, I am not to use equipment without my doctor’s written permission.

My signature below constitutes my acknowledgement that (1) I have read,     understand, and fully agree to the foregoing consent, (2) the proposed cryotherapy 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 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 18 years of age and fully competent; and I execute this release for full, adequate, and complete consideration fully intending to be bound by the same.

Furthermore, I agree that I will comply with all instructions on the use of the cryotherapy devices and that I am sing these services at my own risk.  I agree to use all sessions within the terms of the contract and understand that refunds are not given on unused portions or packages.

 

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*
Second Client Date of Birth*
Second Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Third Client Name

First Name*

Middle Name

Last Name*
Third Client Date of Birth*
Third Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Fourth Client Name

First Name*

Middle Name

Last Name*
Fourth Client Date of Birth*
Fourth Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Fifth Client Name

First Name*

Middle Name

Last Name*
Fifth Client Date of Birth*
Fifth Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Sixth Client Name

First Name*

Middle Name

Last Name*
Sixth Client Date of Birth*
Sixth Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Seventh Client Name

First Name*

Middle Name

Last Name*
Seventh Client Date of Birth*
Seventh Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Eighth Client Name

First Name*

Middle Name

Last Name*
Eighth Client Date of Birth*
Eighth Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Ninth Client Name

First Name*

Middle Name

Last Name*
Ninth Client Date of Birth*
Ninth Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Tenth Client Name

First Name*

Middle Name

Last Name*
Tenth Client Date of Birth*
Tenth Client Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
Client 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*
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Questionnaire
Cryotherapy should not be used if you have the following, please check if you have any of the following:
Pregnancy
Cold activated asthma
Pacemaker
Uncontrolled High Blood Pressure
Other heart conditions
Unstable chest pains
High Blood Pressure
Cold Allergy
History of blood clots
Disease of blood vessels
Nerve pain in feet and legs

You may have other conditions that make whole body cryotherapy inappropriate.  Consult with your doctor or medical advisor if you have questions as to if whole body cryotherapy is appropriate for you.

Are you pregnant?*
No
Yes
N/A - Males
Are you breastfeeding?*
No
Yes
N/A - Males

List any medications that you are taking above

List any allergies that you have above
How did you hear about us?*

If you marked OTHER on the previous question, how did you hear about us?
I hereby grant CRYO252 permission to use my likeness in a photograph, video, or other digital media ("photo") in any and all of its publications, including web-based publications, without payment or other consideration. I understand and agree that all photos will become the property of the CRYO252 and will not be returned. I hereby irrevocably authorize the CRYO252 to edit, alter, copy, exhibit, publish, or distribute these photos for any lawful purpose. In addition, I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photo. *
Yes, I give consent
NO, I do NOT given consent

Date Signed: *
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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