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Human

Orthopedic & Aesthetic

Cryotherapy

NEW CLIENT INTAKE FORM; CONSENT FORM

Human Orthopedic & Aesthetic Localized Cryotherapy Services

To ensure the safety of you and/or minor during any treatment, please take time to

carefully read this form and answer ALL QUESTIONS to the best of your ability.

All information is CONFIDENTIAL and protected – we will never share it with any

third parties, unless required by law.



Introduction: What is localized cryotherapy?

The procedure includes spraying the treatment area with dry Carbon Dioxide (Co2)

vapor carbon dioxide as cold as -108° F, under pressure as high as 725 psi, in short

90-second increments. The combination of precise application, extremely low

temperatures, and high-pressure results in rapid and deep cooling of the affected

tissue, producing better results than traditional cold therapies.

This is not a medical treatment, but can assist in pain management, stimulation of cell

regeneration, and to reduce swelling. The device creates thermal shock in the

system, which improves blood flow in the treatment area and helps reduce

inflammation.

Localized cryotherapy is safe for most animals, but some contradications have

been identified and negative side effects are possible. Familiarizing yourself with

the below information will help you avoid unwanted consequences.



If you/minor have an injury, illness, a serious medical condition, or a health-related

concern, we strongly suggest consulting your primary physhician prior to using localized

cryotherapy.



Advisements and contraindications

Having any of the contraindications described in this document will require you to

use discretion for your own well-being.

Cold applications can feel slightly uncomfortable and leave the skin pink for a short

period following the session, while the skin temperature is returning to normal, but

there is no damage and no recovery required. In case of experiencing burning

sensation, pain, or significant discomfort at any time during our treatments, we

strongly advise you to terminate the session immediately upon your own volition.



Localized pain management high impact cryotherapy 

We use a high-pressure flow of CO 2 to lower the tissue temperature in the treated

area. The process is called cryo-stimulation, causes constriction of the blood vessels in

response to cold, followed by dilation and improved blood flow post-treatment,

reducing inflammation and swelling and stimulating release of hormones like

noradrenaline and Beta-Endorphins which are powerful natural pain killers.

Applications include athletic recovery, recovery from soft tissue, muscle, tendon, or

overuse injuries or surgery, and painful motion-limiting medical conditions.

This treatment does not impose health risks but should NOT be applied to highly

sensitive skin or open wounds and should be avoided in case of cold allergies or

any other cold-induced condition.



Liability waiver

In consideration of using the localized cryotherapy services offered by Country Cryotherapy LLC by filling out and signing this Intake Form prior to or during your first visit.

You have acknowledged the following:

You have been truthful in disclosing your horse’s health conditions, as well as past

health-related events.

You understand that the services provided by Country Cryotherapy LLC, although

they may have certain health benefits, the best source of information about

treatment for your horse is your veterinarian. You have been advised that all

services have contradications and that you should ONLY use any treatments if

you either don’t have the related risks or have discussed these risks with your

veterinarian and obtained their written consent.

You recognize the importance of informing Country Cryotherapy LLC personnel about

any changes in your horse’s condition, including injury, recent surgery or

pregnancy, as they are important for the practitioner to know and may affect

treatment protocols.



You are aware of the need to postpone your appointments with Country Cryotherapy LLC;

if your horse has a fever or communicable infection. The Country Cryotherapy LLC cancellation requirements and package expiration dates still apply.

You have been informed that results are not always immediate, and some benefits

will continue to develop over weeks, or even months, post-treatment. In some

cases, treatment may not show the desired results if it is not the best treatment for

your horse’s condition. It is best to speak to your vet about any treatment plans

and the progress of your horse’s recovery or rehabilitation.

You consent to commit to promptly following all safety and other behavior and

treatment-related instructions, posted through the facility or given to you by Country Cryotherapy LLC personnel.

You accept the responsibility to immediately inform Country Cryotherapy LLC if you

notice any adverse effects from any treatment, as they may indicate the need to

discontinue the service.

You confirm that it has been explained to you, and you understand the

administration of the localized cryotherapy services provided by Country Cryotherapy LLC, including possible adverse reactions, side effects, or complications.

They are rare, but, when extreme cold is involved, minor frostbites may occur and

may lead to long-term sensitivity of the affected area to heat or cold post-event.

Based on the above, YOU VOLUNTARILY ASSUME FULL RESPONSIBILITY for

engaging in the said services and AGREE TO INDEMNIFY AND NOT HOLD Country Cryotherapy LLC and from any consequences and related costs that may 

incur due to your use of any of the treatments.

You also acknowledge that you have been given no warranty or guarantee of any

particular results. You understand that the outcome depends not only on the

treatments, but also diet, lifestyle choices and numerous other factors outside Country Cryotherapy LLC control.



Consent to use the clinical photographs

Except for pain management, clinical photographs play a key role in monitoring

your progress over the weeks of treatment and education of our staff. They also

help inform equipment suppliers in the process of continuous development of new

applications and better technologies.

Different types of consent are required according to the way in which clinical

images will be used. Please CHOOSE ONE of the options below. If you do not fully

understand what each option implies, please ask. Please note that we must take

photographs to monitor your progress; so, at least the lowest level of consent (case

notes) is REQUIRED.

Your choice of consent level will not affect your treatment in any way.



CONSENT TO OPEN PUBLICATION. I give my consent to ANONYMOUS

publication of my progress images in a journal, textbook, marketing materials or

open access websites which may be seen by wellness professionals outside Country Cryotherapy LLC, as well as members of the general public. Anonymity means

focus only on the treated body part and not showing my full face or disclosing my

name.




CONSENT TO RESTRICTED EDUCATIONAL USE. I agree with ANONYMOUS 

use of my progress images, only by professionals for the purposes of cryotherapy

research and education of people seeking to become professionals. Anonymity

means focus only on the treated body part and not showing my full face or

disclosing my name.





CONSENT TO CASE NOTES ONLY. I understand that the illustrations

requested here, to which I have agreed, will only form part of my confidential treatment records and will be used by nobody but the Country Cryotherapy LLC staff

directly involved in providing the services of my choice.








Authorization, waiver, and consent

 I am Self Participant 




I am Parent/Guardian of Minor






I hereby confirm that all information provided by me herein is correct to the best of

my knowledge, and I have disclosed all health-related risk factors that I know of

and will inform Country Cryotherapy LLC of any changes in the horses’ health status.

I have disclosed all medical conditions that I am aware of and I understand that

equine therapy services are designed to be a health aid. This is no way a substitute

for a veterinarian’s care. Information exchanged during a therapy session is

educational in nature and is to be used at my own discretion.

By signing this document, I CONFIRM THAT I HAVE READ, UNDERSTOOD AND

AGREED with the treatment-related risks, liability waiver, and provisions of the Country Cryotherapy LLC Service Terms and Conditions. By signing this document, I

ALSO CONFIRM THAT IT HAS BEEN EXPLAINED TO ME AND I AGREE with the choice

of consent level related to the use of the “before” and “after” photographs.

I am aware that, to withdraw my earlier given consent, that I could do any time

without any impact on the services I will be receiving, I must request it in writing.







September 3, 2026



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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
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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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