Cryotherapy Waiver & Health Screening

AKRON CRYO

Localized Cryotherapy Health Screening, Informed Consent, Waiver and Release Agreement

Please complete every required field. All screening answers require staff assessment before treatment. A “Yes” answer requires staff review.

Customer Information

Customer Name * Date of Birth * Gender

Address *

Cell Phone * E-mail *

Emergency Contact

Contact Name Relationship

Contact Phone Number

Contraindication Screening

Absolute Contraindications

Have you ever had a heart attack within the past 6 months?

Yes No

Do you have a pacemaker?

Yes No

Do you have moderately or severely elevated blood pressure (above 180/95 mmHg)?

Yes No

Unstable angina pectoris: chest pain that occurs without direct cause and will not simply cease by itself (imminent heart attack)

Yes No

Have you had a heart bypass or valvular disease within the past 6 months?

Yes No

Do you have cardiovascular diseases in which symptoms are present?

Yes No

Do you have cardiac arrhythmias?

Yes No

Do you have congestive heart failure?

Yes No

Do you have chronic obstructive pulmonary disease (COPD)?

Yes No

Do you have an intrathecal pain pump or any electrostimulation implant device (for example, a spinal stimulator implant)?

Yes No

Do you have Raynaud’s phenomenon?

Yes No

Do you have intermittent claudication (also called peripheral arterial disease)?

Yes No

Do you have any chronic or acute kidney conditions?

Yes No

Are you pregnant?

Yes No

Relative Contraindications

Do you have a history of seizure disorders?

Yes No

Do you have cold allergies with known skin reactions to cold?

Yes No

Do you have any blood disorders (such as hemophilia or blood clots)?

Yes No

Do you have any major circulatory dysfunction (such as deep vein thrombosis)?

Yes No

Other Risk Factors

Do you have any open wounds, sores, or healing disorders?

Yes No

Are you under the influence of drugs or alcohol?

Yes No

Health screening notice: A “Yes” response means Akron Cryo staff must review the response before treatment. Akron Cryo may decline or postpone treatment and may require medical clearance when appropriate.

Medical Clearance — If Required

If Akron Cryo determines that medical clearance is appropriate based upon your health history, contraindications, medications, medical conditions, or other risk factors, Akron Cryo will contact you before treatment. The determination of whether medical clearance is required is made by Akron Cryo staff and is not selected by the customer on this form.

Description of Localized Cryotherapy

Localized cryotherapy involves the controlled application of very cold temperature to a selected area of the body for a limited period of time.

The purpose of the service is to provide localized cold exposure. Individual responses to cryotherapy vary, and no particular result is guaranteed.

I understand that I may ask the technician to stop the treatment at any time if I experience pain, excessive discomfort, numbness, burning, unusual skin sensation, dizziness, shortness of breath, or any other concerning symptom.

Acknowledgment of Risks

I understand that localized cryotherapy involves exposure of the skin and underlying tissues to very cold temperatures.

Possible reactions may include temporary redness, numbness, tingling, discomfort, skin irritation, changes in skin sensation, or other reactions associated with cold exposure. Although reasonable precautions are taken, I understand that adverse reactions may occur.

I agree to immediately notify Akron Cryo staff if I experience unusual discomfort or any symptom that concerns me during treatment.

Customer Health Representation

I certify that the information I have provided on this form is complete and accurate to the best of my knowledge. I understand that Akron Cryo relies upon the health information I provide when determining whether a service may be appropriate for me.

I agree to inform Akron Cryo of any material change in my medical condition, medications, pregnancy status, implanted medical devices, cardiovascular condition, circulation problems, skin condition, or other relevant health information before receiving future treatments.

I understand that Akron Cryo personnel are not providing a medical diagnosis and that cryotherapy services are not a substitute for evaluation, diagnosis, or treatment by a licensed medical provider.

Voluntary Participation and Assumption of Risk

I voluntarily choose to receive services from Akron Cryo, LLC. I understand that participation may involve risks, including risks that may not presently be known or reasonably foreseeable.

Having had the opportunity to ask questions regarding the service, I voluntarily accept the risks associated with my participation.

Release of Liability

In consideration of being permitted to participate in services provided by Akron Cryo, LLC, I agree, to the fullest extent permitted by applicable law, to release and hold harmless Akron Cryo, LLC and its owners, officers, employees, agents, contractors, and volunteers from claims arising from the ordinary and inherent risks associated with my voluntary participation in the service.

Nothing in this agreement is intended to waive any right or remedy that cannot legally be waived under applicable law.

If any portion of this agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in effect to the fullest extent permitted by law.

No Guarantee of Results

I understand that individual responses to cryotherapy vary. Akron Cryo, LLC does not guarantee any particular therapeutic, cosmetic, recovery, pain-relief, weight-loss, body-contouring, or other outcome from localized cryotherapy.

Cryotherapy services are not intended to diagnose, treat, cure, or prevent any disease unless specifically provided under the direction of an appropriately licensed healthcare professional.

Treatment Area Acknowledgment

Before treatment begins, I will identify the area or areas I wish to have treated. I understand that I may decline treatment of any area and may request that treatment be stopped at any time. I will immediately tell the technician if the treatment becomes uncomfortable or if I experience an unexpected reaction.

Customer Initials *

Confirmation of Health Screening

I confirm that I have reviewed and answered the health screening questions contained in this form. I understand that withholding relevant health information may increase the risk associated with receiving cryotherapy.

Customer Initials *

Confirmation of Waiver

I have read this waiver, or it has been read and explained to me. I have had an opportunity to ask questions. I understand that this agreement contains a release of liability and that I am voluntarily agreeing to its terms.

Customer Initials *

Signature Print Name * Signature *

Date *

Parent/Guardian Consent (Required for Customers Under 18)

Customers younger than 14 are not eligible to submit this waiver. Customers who are at least 14 but younger than 18 require a parent or legal guardian signature.

I certify that I am the parent or legal guardian of the minor named above and that I have authority to consent to the minor’s participation. I have reviewed the health screening information and this agreement and voluntarily consent to the minor receiving the selected Akron Cryo service.

Parent/Guardian Name Relationship

Parent/Guardian Signature

I certify that the information I provided is accurate and I consent to use of this electronic signature as my signature on this waiver. *

I acknowledge the Privacy Policy and agree to the Terms of Use. *

This form contains sensitive health information. Akron Cryo uses it for screening, service administration, and recordkeeping as described in the Privacy Policy. Do not submit information you do not want Akron Cryo to receive.

AKRON CRYO

Dolphin Neurostim Client Consent Form

Please complete every required field. All screening answers require staff assessment before treatment. A “Yes” answer requires staff review.

Client Information

Client Name * Date of Birth * Gender

Address *

Cell Phone * E-mail *

Emergency Contact

Contact Name Relationship

Contact Phone Number

Contraindication Screening

Absolute Contraindications

Do you have a pacemaker?

Yes No

Are you pregnant?

Yes No

Do you have epilepsy or seizures? (No treatment above the neck.)

Yes No

Do you have cancer?

Yes No

Medical Clearance — If Required

Informed Consent

In order for us to provide treatment for your condition(s) it is necessary for you to give your informed consent. Such treatments may include electrical stimulation which has the following contraindications:

Pacemaker
Pregnancy
Epilepsy/Seizures (no treatment above the neck)
Cancer

Electrical stimulation or “e-stim,” involves the use of electric devices such as TENS (Transcutaneous Electrical Nerve Stimulation), or MENS (Microcurrent Electrical Nerve Stimulation).

I have read and understand all of the above information and by signing below I consent to treatment.

I understand that I may not receive treatment until I understand this consent form and have signed it.

Client Initials *

Signature Print Name * Signature *

Date *

Parent/Guardian Consent (Required for Clients Under 18)

Clients younger than 14 are not eligible to submit this waiver. Clients who are at least 14 but younger than 18 require a parent or legal guardian signature.

Parent/Guardian Name Relationship

Parent/Guardian Signature

I certify that the information I provided is accurate and I consent to use of this electronic signature as my signature on this waiver. *

I acknowledge the Privacy Policy and agree to the Terms of Use. *