CRYO FORM | The Healing Center

Cryotherapy & Infrared Sauna

Waiver

Name: *

Home Address *

City *

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Phone: *

Email: *

Date of Birth *

Height *

Weight *

Referral From:

If no referral, how did you hear about us?

Emergency Contact: *

Contact Phone Number: *

List any medications you are currently taking, the condition associated with it, and the respective doses: *

Are you currently under medical care for any reasons? Please explain: *

List any allergies: *

Please indicate if you have any of the following conditions and explain: High Blood Pressure, Diabetes, Tension Headaches, Joint & Muscle injuries, Paralysis, Respiratory Disease, Migraines, Areas fo Numbness, Cancer, Joint Disease, Kidney Disease, Infectious Disease, Skin Disease, Stroke, Pregnancy, Heart Disease, Areas of Chronic Pain, Aneurysm, Blood Clot, Blood Thinner: *

**UPON ANY CHANGE IN MEDICAL HISTORY AND/OR MEDICATIONS, THE CLIENT IS RESPONSIBLE TO REPORT DETAILS TO STAFF TO ENSURE CLIENT SAFETY. CONTRADITIONS TO USING WHOLE BODY CRYOTHERAPY: Pregnancy, Severe Hypertension )BP > 160/100), Acute or Recent Myocardial Infarction, Unstable Angina Pectoris, Arythmia, Symptomatic Cardiovascular Disease, Cardia Pacemaker, Stroke, peripheral arterian inclusive disease, venous thrombosis, acutre of recent cerebrovascular accident, uncontrolled seizures, Raynaud's Syndrome, Fever, Tumor disease, Symptomatic lung disorders, Bleeding Disorders, Severe Anemia, Infection, Calustrophobia, Cold Allergy, Acute Kidney & Urniary Tract Diseases, Under the age of 18 (parental concent needed). INITIAL BELOW if you have read and confirm you DO NOT have any of these conditions. *

Whole Body Cryotherapy is the exposure of a person's skin to temperatures of -150 -170 degrees celsius (1238 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 medicatl and cosmetic benefits. 1. You must wear cotton or wool socks (and underwear for 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 devoic of oxygen and may cause fainting. 4. During treatment you must keep your hands visbile to the operator at the upper rim of cryo cabin as instructed. 5. You may end the procedure at any time if you experience any problems or anxiety. 6. Abnormal skin sensitivity to cold may be cause by certain foods, cosmetics, or medications, including but not limited to the following: tranquilizers, high blood pressure medication. 7. A person who is less than 18 years of age must have parental concent. 8. Children under the age of 14 are prohibited from the cryotherapy due to the inability to regulate body temperature. INITIAL BELOW *

CONTRAININDICATIONS to using WHOLE BODY CRYOTHERAPY: Pregnancy, Sever Hypertnsion (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, Symptomaitc Lung Disorders, Bleeding Disorders, Serve Anemia, Infection, Calustrophobia, Cold Allergy, age less than 18 yearss (parental consent required), cute Kidney & Urinary Tract Disease. INITIAL BELOW *

Risk 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 a peripheral circulation returns to normal), allergic reaction to extreme cold (rare), calustrophobia, anxiety, activation of some viral conditions (cold sores) etc. due to stimulation of the immune system. INITIAL BELOW *

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 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. Beacuse 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 meidcal profile and understand that there shall be no liability on the therapists 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 proposted 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 concent. 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, fanchisers, or manufactures 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 (18) years of age and legally competent; I HAE 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 equipment and that I am using these services at my own risk. I agree to use all sessions within the terms fo the contract dates and understand that refunds are not given on unused portions of purchased packages. INITIAL BELOW *

Participants Name / Date *

Participants Parent/ Legal Guardian Name / DATE *

DIGITAL SIGNATURE: Please Provide Your Digital Signature below / Date: *

SELF-CARE RELEASE for INFRARED SAUNA. Have you consulted your doctor regarding your ability to use the infrared sauna? If no, it is recommended that you talk with your docotr before using the infrared sauna. The Use of drugs, medications, or alcohol pirior or during the sauna session may lead to dizziness or unconsciousness. No one under teh age of 18 is permitted in the infrared sauna unless accompanies by a supervising adult. Older patients should consult their physicial before using the infrared sauna. Discontinued the use of the sauna and or jade massage table if you feel light-headed, dizzy or heat exhausted. IINITIAL BELOW *

SELF-CARE CONSENT FORM. Sauna sessions should be limited to no more than 30 minutes and temperatures must stay below 150 degrees Fahrenheit. Jade table sessions should be limited to 20 minutes. It is always important to maintain proper hydration levels during infrared and jade therapy. Please consult your physician if you are in doubt regarding your ablility to use the far infrared sauna or jade table for health reasons. INITIAL BELOW *

SELF-CARE ACKNOWLEDGEMENT. I acknowledge and voluntarity assume the risk of injury, accident or death, which may arise from the use of the self-care area. I and any of my heirs, executors, representatives or assigns hereby release all calims or liabilities for personal injury or property damages of any kind sustained while on the premises, during the use of the self-care area and from any advice provided by an employee, independent contractor or any representative. I agree that this applicaiton and waiver is in effect for all self-care sessions and will not expire unless spcifically request by either party. PLEASE PROVIDE YOUR DIGITAL SIGNATURE AND DATE BELOW *

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Cryotherapy & Infrared Sauna

Waiver