Have you had a Heart Attack within the previous 6 months?
Do you have a Pacemaker?
Have you had a Heart Bypass or Valvular Disease within the previous 6 months?
Do you have Congestive Heart Failure?
Do you have Chronic Obstructive Pulmonary Disease (COPD)?
Do you have peripheral arterial occlusive disease?
Circulatory Risk Factors Do you have any major circulatory dysfunction?
Do you have any known cold allergies or have hypersensitivity to cold?
Do you have any blood disorders?
Do you have Intrathecal Pump Implant (pain pump)?
Do you have Deep Vein Thrombosis (DVT)?
Do you have any open wounds, sores or healing disorders?
Are you Pregnant?
Do you have a history of Seizure Disorders?
Do you have kidney disease?
Are you under the influence of drugs or alcohol?
Hypertension (BP> 180/100)?
Unstable angina pectoris?
Symptomatic lung disorders?
Acute kidney and urinary tract diseases?
Severe Anaemia, infection?
Any other major disease or diagnosis? Please state
WAIVER AND RELEASE AGREEMENT
PLEASE READ CAREFULLY BEFORE SIGNING
Physical Capability Requirements Participation in a Whole Body Cryotherapy (WBC) session involves exposure to extreme cold temperature for a short period of time (not to exceed three (3:00) minutes per session).
During the WBC session, the cryosauna technician will be present during the entire duration of your session.
LIABILITY AND MEDICAL RELEASE AND INDEMNIFICATION AGREEMENT In consideration of being permitted by Cryo HQ South Pacific Pty Ltd to participate in their services, I hereby waive 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:
1.This release is intended to discharge in advance Cryo HQ South Pacific Pty Ltd, its 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;
2.Participation may involve risk of serious injury, 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, Cryo HQ South Pacific Pty Ltd employees, or volunteers and may result from the conditions of the facilities, equipment, or areas where such activities are being conducted;
4.Fluctuations in blood pressure (due to peripheral vasoconstriction, blood pressure may briefly increase by up to 10points systolically during treatment. This effect should reverse after the end of the procedure, as peripheral circulation returns to normal)
5.Knowing the risks involved and the contraindications related, I nevertheless chose voluntarily to request permission to participate;
6.I will indemnify and hold harmless Cryo HQ South Pacific Pty Ltd, 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;
7.I am in good health and have no physical condition expressed in the 'Contraindications' or otherwise which would preclude me from safely participating in such activities;
8.I may end the procedure at any time if I experience problems or anxiety;
9.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;
10.I understand and agree that this release is intended to be as broad and inclusive as permitted under the law of the State in which it is executed 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 HAVE CAREFULLY READ THIS RELEASE INDEMNIFICATION AND HOLD HARMLESS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A POTENTIAL CONFLICT BETWEEN MYSELF, AND MY HEIRS AND CRYO HQ SOUTH PACIFIC PTY LTD I VOLUNTARILY AGREE TO EACH OF THE TERMS AND PROVISIONS HEREIN AND SIGN THIS OF MY OWN FREE WILL.
I understand that it is mandatory to wear mittens/gloves, socks and enclosed footwear during my Whole Body Cryotherapy (WBC) session as a safety precaution.
I also understand that I should not remove Personal Protective Equipment (PPE) at any time during my Whole Body Cryotherapy (WBC) session.
I understand that wet or damp clothing cannot be worn at anytime during a Whole Body Cryotherapy (WBC) session. I have dry skin without recent application of lotions and moisturisers.
I have completely read this waiver.
If under 18 years of age, parental consent is required. Separate additional consent form available at the front desk. Customers are required to be a minimum of sixteen (16) years of age for use of the whole-body cryotherapycryosauna.
I authorise Cryo HQ South Pacific Pty Ltd to take and use images of me during my Whole Body Cryotherapy (WBC)
session on social media.
I consent to recieve communication sent from Cryo HQ South Pacific Pty Ltd via email, phone or text messages.
Lastly, If you could take the time to tell us how you heard about Cryo HQ South Pacific?