Intake Form

WAIVER AND RELEASE FORM

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Name *

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Last

Phone Number *

Email *

Address (please include unit/apartment # in line two if applicable) *

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City

State

Zip Code

Country

Birthday *

Referred By: *

Cryotherapy Contraindications: Listed below are absolute contraindications (conditions that render Cryotherapy inaccessible to user). If you have any of the following you may not participate in Cryotherapy treatments and by signing below you confirm you agree with the following statements:
- I HAVE NOT had a heart attack within the previous 6 months
-I DO NOT have a pacemaker
-I DO NOT have Congestive Heart Failure
-I DO NOT have Raynaud's disease
-I AM NOT allergic or sensitive to the cold
-I DO NOT have an open wound track or lesions
-I DO NOT have a seizure disorder
-I AM NOT pregnant
-I DO NOT have an active infection
-I HAVE NOT had chemo or radiation in the last 6 months
-I DO NOT have Trophic Disorders or Tissue Lesions
-I DO NOT have high blood pressure
-I DO NOT have Severe Anemia

By clicking below you confirm your consent to use this as an e-signature *

Accept this check as my e-signature

Liability and Medical Release Indemnification Agreement: In consideration of being permitted by ICE Recovery and Wellness to participate in the whole body walk-in chamber cryotherapy treatments, I hereby wave any and all claims and damages for personal injury or death, which may occur, as a result of my participation. I understand and agree that:
-This release is intended to discharge in advance ICE Recovery and Wellness, it's officers, officials, employees, agents and volunteers from and against all liability arising out of or connected in any way with my participation in these activities.
-Participation may involve risk or serious injustice, illness, disability, or death and may result not only as a result of my actions, negligence or inaction, but also from the action, negligence or inaction of others, including their owners, officers official employees, or volunteers and may result from the condition of the facilities, equipment, or areas where such activities are being conducted.
-Knowing the risks involved and contraindications related, I nevertheless chose voluntarily to request permission to participate understanding that the results of this treatment could include burn, allergic reactions, claustrophobia, lightheadedness/dizziness, tingling, rashes, or reddening of skin.
-I will indemnify and hold harmless ICE Recovery and Wellness, its owners, officers, officials, employees, and volunteers from any loss, liability, damage, cost, or expense, including litigation of any form, arising out of or connected in any manner with my participation in such activities.
-I am in good health and have no physical condition expressed in the above contraindications or which would preclude me from safely participating.
-I understand and agree that this release is intended to be as broad and inclusive as permitted under California law and that if any portion of this Hold Harmless, Release and Indemnification Agreement should be determined to be invalid, it is my intent that the remaining provisions shall continue in full force and effect.
-I understand that a visual monitoring device is used throughout ICE Recovery and Wellness for safety purposes. I understand that all body parts must have comfortable clearance from the inner rim of the chamber.

BY CLICKING BELOW YOU CONFIRM YOUR CONSENT TO USE THIS AS AN E-SIGNATURE *

Accept this check as my e-signature

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