Online Waiver 2019-07-09T22:00:08+00:00

Treatment Consent and Liability Waiver

Please complete form below prior to service

Waiver and Release Agreement. Please read carefully before signing.

THIS IS A RELEASE OF LIABILITY AND A WAIVER OF CERTAIN LEGAL RIGHTS

Participation in Cryotherapy involves exposure to extreme cold temperatures for a short period of time (not to exceed three (3) minutes per session. Below is a list of Absolute Contraindications which will preclude you from participation. In addition, PLEASE BE AWARE, that if you experience any pain or mental or physical discomfort at any time during the whole process, you are advised to terminate the session immediately upon your own volition. You will be observed by a technician the entire time while in the chamber, but are free to stop the treatment and exit the chamber at any time.

Absolute Contraindications (Participation in cold therapy not allowed)

Untreated Hypertension
• Heart attack within previous 6 months
• Unstable Angina Pectoris
• Peripheral Arterial Occlusive Disease
• Ischemic heart disease
• Severe Anemia
• Pacemaker
• Raynaud's disease
• Seizure disorders
• Polyneuropathies
• Pregnancy
• Vasculitis
• Claustrophobia
• Hyperhidrosis - heavy perspiration
• Alcohol and drugs relative contraindications
• Diabetes
• Decompensating diseases (edema) of the cardiovascular and respiratory system; congestive heart failure, COPD, chronic liver disease
• Deep Vein Thrombosis (DVT) or known circulatory dysfunction
• Acute febrile respiratory (Flu like respiratory conditions) Acute kidney and urinary tract diseases
• Cold Allergenic Phenomenon (known allergy to cold contactants)
• Heavy consumerist diseases (abnormal bleeding)
• Bacterial and viral infections of the skin, wound healing disorders (open sores or discharging wound/skin conditions)
• Valvular heart disease condition after heart surgery

This list was developed as a consensus list at a Medical Symposium in 2006 and agreed upon in writing by twelve attendees. It of course may not be all inclusive, so if you have any particular health problem which you believe would preclude you from participating in exposure to extreme cold, please check with your treating physician before participating.

Whole Body Cryotherapy

Safety Instructions for Whole Body Cryotherapy:

1. You must wear cotton or wool socks (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. You may end the procedure at any time if you experience any problems or anxiety

4. 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;

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

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

Risks of whole body cryotherapy:

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

Risks of Firming Lotion:

Allergic reactions of the skin. The lotion contains the following ingredients: Hydroquinone, Tretinoin, (may contain Hydrocortisone and Clindamycin as well). Please notify us if you have a history of allergic reactions to any of these ingredients. We recommend to do a spot test of the lotion 24-48 hours prior to application.

Air-Relax Leg Compression System Contraindications and Risks:

Do not use Air-Relax Leg Compression Device Treatment if you have or may have any of the following conditions: current or unstable fractures or breaks, recent surgery and have sutures or stitches, open wounds, contusions, or abrasions. If you have any other injury, illness or medical condition, you should consult your physician prior to using the Air-Relax Leg Compression System. Possible associated risks include but are not limited to: cut off circulation due to pressure, contusion/bruising. Other extreme cases include, but are not limited to, the risks identified in the cryotherapy risks described above, and herein include but are not limited to blood clots, heart attack, stroke, and/or death.

I HAVE READ, UNDERSTOOD, AND ACKNOWLEDGE THE ABOVE INFORMATION INCLUDING THE ABSOLUTE CONTRAINDICATIONS. I AFFIRM THAT I DO NOT HAVE ANY OF THE CONDITIONS LISTED IN THE ABSOLUTE CONTRAINDICATIONS SECTION. If PARTICIPANT IS A MINOR, I AFFIRM THAT I AM LEGAL GUARDIAN AND ACKNOWLEDGE THAT PARTICIPANT HAS NONE OF THE ABOVE LISTED CONDITIONS. SIGNATURE:

Waiver of Liability and hold Harmless Agreement

1. In consideration for participating in services with CryoMIST, including using the cryotherapy machines (Equipment), Air-Relax Leg Compression Devices, or other services provided by CryoMIST, I hereby release, waive, discharge, and hold harmless CryoMIST, Cryotherapy of Solana Beach, its officers, servants, agents, liquid nitrogen suppliers, 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 the equipment.

2. I hereby confirm that no warranty or guarantee, or other assurance, has been made to me covering the results of the above 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 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.

3.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 releasees from any loss, liability, damage or costs that may incur due to the use of Equipment by me.

4. 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, 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 California.

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

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

My signature below constitutes my acknowledgment that (1) I have read, understand, and fully agree to the foregoing consent, (2) the proposed cryotherapy, leg compression therapy (or other services) 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 am informed of 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 eighteen (18) years of age and fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same.

Furthermore, I agree that I will comply with all instructions on the use of the devices at CryoMIST 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. Also, sessions at CryoMIST are provided on an Appointment basis. I understand that if I do not show for my appointment, or if I cancel within 12 hours prior to my scheduled time, I will be subject to a $10 late cancellation fee. This fee will be debited directly from the bank account on file.

If I purchase a monthly membership, I am entitled to a set number of Cryotherapy sessions per month at a reduced rate. Max 1 session per day. Commitment to membership is 3 months, and I may cancel any time after that with a 30-day notice. My account will be auto-debited each month while enrolled. If I cancel my membership, I will be subject to the 3-month commitment upon re-enrollment. Unused sessions do not roll-over to the next month, and I may not receive refunds for unused portions, or if I cancel after being charged.