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Cryotherapy, Fire N Ice Facial, Local Cryo, T Shock, Compression Therapy, Nanovi, Red Light and Celluma User Agreement

PLEASE READ CAREFULLY BEFORE SIGNING

Agreements:

  1. Follow all instructions given to you by the attendant. Do not use whole body cryotherapy / local cryotherapy without an attendant present.
  2. 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 avoid inhaling the nitrogen gas that is emitted into the equipment. 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 / local cryotherapy. You also agree to only using 1 Whole Body Cryo session per day maximum.
  3. 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 therapeutic nature or other benefits of whole body cryotherapy / local cryotherapy.  Whole body cryotherapy / local cryotherapy are not intended to diagnose, treat, cure or prevent diseases, illnesses, imbalances or disorders.  No results from whole body cryotherapy / local cryotherapy are assured.  Every customer is different and responds differently to the therapy.

Mandatory Safety Instructions for whole body cryotherapy / local cryotherapy:

  1.  You must wear our cotton or wool socks, briefs for men, to minimize the potential of chilblain and other potential injuries from over exposure to cold temperatures;
  2.  Sessions are limited to 3 minutes per session to minimize the potential for such adverse effects from over exposure to cold temperatures;
  3.  During the session, you must ensure that your head remains above the level of, and avoid inhaling, gasiform air
    (the cloudy gas circulating in the cryochamber); while non-toxic, it is devoid of oxygen and may cause shortness of breath, fainting, or other conditions;
  4. You must immediately notify the attendant and the end of the session if you at any time experience any
    physical or mental discomfort, problems, pain or anxiety;
  5. Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, lotions, piercings, or medication,
    including, but not limited to, tranauilizers and high blood pressure medication- do not use whole body cryotherapy / local cryotherapy if you have
    reason to believe you have come in contact with or ingested any such product.
  6. A person who is less than (18) years of age may not use whole body cryotherapy without written parental
    consent;
  7. A person who is less than (16) years of age may not use whole body cryotherapy even with parental consent.
  8. All body parts must have a comfortable clearance from the inner rim of the chamber during treatment.

Cryo T- Shock safely and effectively uses thermal shock to naturally destroy fat cells without any damage to the skin. The Cryo T-Shock breaks down fat cells, which your body naturally flushes out through the bloodstream and then the lymphatic system in days to weeks following the treatment. Cryo T-Shock also helps reduce the appearance of cellulite, fine lines and wrinkles by stimulating collagen and elastin production while tightening muscles. Cryo T-Shock is also beneficial for facial toning and lifting. Protocols will be discussed and or adjusted during consultation based on recommendations and client’s needs.

I understand that results may vary depending on individual factors including but not limited to medical history, prior treatments of area being treated, skin type, patient compliance with pre/post care instructions and individual response to treatment. I understand that for purposes of fat/cellulite reduction/skin toning, I must maintain good dietary habits, have sufficient intake of water and participate in light physical activity as well as comply with other items outlined during consultation.

•  Cryo T-Shock should not be applied over inflamed, infected, or swollen areas of the skin.

•  Cryo T-Shock should not be applied over/near cancerous areas or on clients undergoing active chemotherapy.

•  Cryo T-Shock should not be used on clients who suffer from Kidney Disease.

•  Cryo T-Shock should not be used on clients on dialysis.

•  Cryo T-Shock should not be used on clients who are pregnant.

•  Cryo T-Shock should not be used on clients who suffer from Severe Diabetes where sensation has been lost in the extremities.

I understand that any procedure involves risk. Risks may include redness, swelling, irritation, skin reaction, or increased heart rate. Some may experience delayed onset muscle soreness from treatments on the stomach due to unintentionally engaging the abdominals, which disappear later that same day.

I have been honest and forthright about my medical history, and am healthy to use the device. I am not pregnant, nor any other disease or condition that may be negatively impacted by the Cryo-T Shock Treatment.

Waiver and Release:

  1. This is a release of liability and a waiver of certain legal rights.
  2. By signing this Agreement you:
    a.  acknowledge that use of whole body cryotherapy / local 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 / local 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 / local 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 / local 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:

  1. 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 / local cryotherapy, with the words, terms, provisions, covenants, and remedies contained in this Agreement to be enforceable to the fullest extent permitted by applicable law.
  2. If any portion of this Agreement is held invalid, the remainder shall not be affected and shall continue in full legal force and effect.
  3. The terms of this Agreement shall continue from this date forever and shall apply to each use by you of whole body cryotherapy / local cryotherapy without the need for you to re-execute this Agreement.
  4. This document constitutes the entire agreement regarding your use of whole body cryotherapy / local 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 / local cryotherapy.  This Agreement may only be modified in a writing signed by you and an authorized representative of the Company.  

Risks of whole body cryotherapy and local cryotherapy include, but are not limited to: fluctuations in blood pressure (due to peripheral vasoconstriction, systolic blood pressure may briefly increase by up to 10 points during the session. This effect should reverse after the end of the session, as peripheral circulation returns to normal), allergic reaction to extreme cold (rare), clautrophobia, anxiety, activation of some viral condtion (cold sores) etc. due to stimulation of the immune system. One primary inherant risk of cryotherapy is skin senstivity and skin irritation. It is impossible to predict how client’s skin will react during or after cryotherapy.

Normatec Pulse Technology Contraindications: Do not use Normatec Pulse technology if you have any of the following conditions: current or unstable fractures or breaks, recent surgery, sutures, stitches, open wounds, or abrasions. If you have any other injury, illness or medical condition you should consult your physician prior to using Normatec.

Fire N Ice Spray Active Ingredients: The following are the active ingredients in the Fire and Ice Treatment.    Some of these ingredients could have an allergic or a negative reaction.  This product is not intended to diagnose, treat or cure or prevent disease. These statements have not been evaluated by the Food and Drug Administration: Water, Caprylic/ Capric, Triglycerides, Polysorbate 60, Glycerol, Propylene Glycol, L-2- Aminopropanoic Acid, Inosine, Niacinamide, Glycine, Methyl Nicotinate, L-Histidine, Copper Peptides, Phosphatidyl Choline, d-Tocopherol and mixed (alpha, beta, gamma, delta) Tocopherols, Ascorbyl Palmitate, Lyso Phosphatidyl Choline, Oleic Acid, Pyridoxal-5-Phosphate, Ethanol, Glyceryl Stearate, phenoxyethanol, Rosmarinus Officinalis.

I understand and agree that all Sessions will expire 2 years from the date of purchase. 

BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I HAVE READ AND UNDERSTAND THE "CONSENT, RELEASE AND INDEMNITY AGREEMENT" FOR THESE TREATMENTS, AND THAT I AM SIGNING IT VOLUNTARILY.   SHOULD ANY PAIN OR DISCOMFORT OCCUR I WILL IMMEDIATELY NOTIFY THE LUX CRYO WELLNESS STAFF. I UNDERSTAND THAT I MUST BE AT LEAST 18 YRS OLD TO PARTICIPATE IN THESE TREATMENTS. I UNDERSTAND THAT ALL SALES ARE FINAL AND REFUNDS ARE NOT PREMITTED.

 

Date: October 26, 2021

First Client's Name

First Name*

Last Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
First Client's Signature*
Second Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Second Client's Signature*
Third Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Third Client's Signature*
Fourth Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Fourth Client's Signature*
Fifth Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Fifth Client's Signature*
Sixth Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Sixth Client's Signature*
Seventh Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Seventh Client's Signature*
Eighth Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Eighth Client's Signature*
Ninth Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Ninth Client's Signature*
Tenth Client's Name

First Name*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
Tenth 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's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
FOR MINORS, ONLY:

Emergency Contact
How Did You Hear About Us?
How did you hear about us?*
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*

Relationship*

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

Contraindications:

Do not use Whole Body Cryotherapy if you have any of the following conditions: check all that apply:
Uncontrolled high blood pressure
Prior heart attack
Unstable chest pain
Disease of blood vessels
History of blood clots
Cold Allergy
Open sores
Nerve pain in feet or legs
Pregnancy
Joint Disease

If you've selected any of the boxes above, please explain the details of each.
Please check each service that you may be interested in: *
T Shock Fat Loss
Whole Body Cryo
Local Cryo
Normatec
Nanovi
Fire N Ice Facial
Celluma
Red Light Therapy
What is your skin type?
Normal Skin Type
Oily Skin Type
Blackheads
Breakouts
Sensitive/ Redness
Are you currently taking or using any products that could make your skin sensitive?*
No
Yes

List all known allergies.
Do you have any health issues or injuries that would prevent you from safely using any of our services?*
No
Yes

If yes, please explain:
If you are doing T Shock treatments, do you give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.*
No
Yes
Each person has a different response to the Cryo T-Shock treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. Do you agree to have your photograph taken to document your results and they will not be used for marketing unless agreed upon (see above).*
No
Yes
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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