General medical and media release
Subzero Slimming/Fat Reduction:
Absolute NO:
- Active Cancer
- Severe Raynaud’s Syndrome
- Allergies to Cold, Heat, or Propylene glycol
- Cold-related Illness (Cryoglobulinemia, Paroxysmal Cold Hemoglobinuria, Cold Agglutinin Disease)
- Lower Limb Ischemia
- Uncontrolled Diabetes or Diabetes-related complications
- Severe Kidney or Liver Disease
- Pregnancy/Breastfeeding
- Fillers in the desired treatment area in the past 4 weeks
- Bacterial and viral infections of the skin
- Active/Severe Eczema, Rashes, or Dermatitis in the desired treatment area
- Silicone/other implants in the desired treatment area
- Irremovable body piercings in the desired treatment area- Go around, not over.
- Open or infected wounds in the desired treatment area
- Impaired skin sensation in the desired treatment area
- Undiagnosed lumps or bumps
- PAD and PVD
Consult physician:
- Past Cancer
- Acquired or autoimmune diseases
- Progressive Diseases (including but not limited to MS, ALS, Parkinson’s, and Neuropathy)
- Cardiovascular Disease
- Lymphatic Disorders
- Wound healing disorders
- Severe Eczema, Rashes, or Dermatitis outside the desired treatment area
- Circulatory disorders
- Use of topical antibiotics in the desired treatment area
- Any major surgery in the past 6 months
- Metal implants in or adjacent to the desired treatment area *Mesh inserts in or adjacent to the desired treatment area *Hernia in or adjacent to the desired treatment area
- Active implanted devices such as pacemakers or defibrillators
- Any serious health condition not specified
- Undiagnosed lumps or bumps
- Epilepsy
- History of DVT
Subzero Facial
Absolute NO:
- Severe Raynaud’s Syndrome
- Allergies to Cold or Propylene glycol
- Active Cancers
- Cold-related Illness (Cryoglobulinemia, Paroxysmal Cold Hemoglobinuria, Cold Agglutinin Disease)
- Lower Limb Ischemia
- Anti-Wrinkle injections in the desired treatment area in the past 14 days
- Fillers in the desired treatment area in the past 4 weeks
- PDO threads in the past 90 days
- Bacterial and viral infections of the skin
- Active/Severe Eczema, Rashes, or Dermatitis in the desired treatment area
- Silicone/other implants in the desired treatment area
- Irremovable body piercings in the desired treatment area- Go around, Not over.
- Open or infected wounds in the desired treatment area
- Impaired skin sensation in the desired treatment area
- Undiagnosed lumps or bumps
Consult physician:
- Past Cancer
- Acquired or autoimmune diseases
- Pregnancy/Breastfeeding
- Progressive Diseases (including but not limited to MS, ALS, Parkinson’s, and Neuropathy)
- Cardiovascular Disease
- Wound healing disorders
- Circulatory disorders
- Use of topical antibiotics in the desired treatment area
- Surgery in or adjacent to the desired treatment area in the past 6 months
- Metal implants in or adjacent to the desired treatment area
- Mesh inserts in or adjacent to the desired treatment area
- Hernia in or adjacent to the desired treatment area
- Active implanted devices such as pacemakers or defibrillators
- Severe Eczema, Rashes, or Dermatitis outside of the desired treatment area
- Any serious health condition not specified
- Undiagnosed lumps or bumps
- Epilepsy
Media
In participating in the Services, you may be photographed, videoed or otherwise recorded by the Company for safety, monitoring and training purposes. You hereby consent to such usage of your imagery for all and any such purpose by the company and hereby agree that the Company without any payment to you shall in all cases be the sole owner of all intellectual and other proprietary rights therein without any restriction whatsoever. If photographs are used for education and/or marketing purposes, all identifying marks will be cropped or removed. Your participation in the Services will expose you to extremely cold temperatures. I have read this Assumption of Risk. Waiver, and Release, fully understand its terms, and understand that I am giving up substantial rights, including my right to sue the Company under certain circumstances. I acknowledge that I am signing this waiver freely and voluntarily. The term of this waiver is indefinite. I acknowledge that I have been urged to avoid bringing valuables into and onto the Company’s facilities and the Company shall not be liable for the loss of, theft of, or damage to my personal property, including items left in lockers, bathrooms, or anywhere else in the Company's facilities. I acknowledge that no portion of any fees paid by me is in consideration for the safeguarding of valuables.
Photo Consent
Pictures will be obtained for records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed, unless treatment is done on the face.
*** By using the electronic signature, I agree to have read and agree to the legal agreement above.
Cryotherapy Consent Form
By engaging America Cryo LLC (for the purposes hereof referred to together herein as the “Company) to provide America Cryo Device Service(s), and using the Company’s equipment and facilities in relation thereto, I hereby acknowledge on behalf of myself, my heirs, personal representatives and/or assigns, that there are certain inherent risks and dangers associated with receiving Services and my use of the Company’s equipment and facilities. At all times, I shall comply with all stated and customary terms, posted safety signs, rules and verbal instructions given to me by staff. If in the subjective opinion of the Company’s staff, I would be at physical risk in receiving Services, I understand and agree that I may be denied access to Services until I furnish the Company with an opinion letter from my medical doctor, at my sole cost and expense, specifically addressing the Company’s concerns and stating that my physician has cleared me to participate in these services.
I hereby agree to
- (1) assume full responsibility for any and all injuries or damages which are sustained or aggravated by me in relation to my receiving of the Services
- (2) release, indemnify, and hold harmless the Company, its direct and indirect parent, subsidiary affiliate entities, CryoCon and each of their respective owners, officers, directors, members, employees, independent contractors, representatives and agents, and each of their respective successors and assigns and all others, from any and all responsibility, claims, actions, suits, procedures, costs, expenses, damages, and liabilities to the fullest extent allowed by law arising out of or in any way related to the Services
- (3) represent that:
- (a) I have no medical or physical condition that would prevent me from receiving the Services
- (b) I do not have a physical or mental condition that would put me in any physical or medical danger
- (c) I have not been instructed by a physician to no receive Services
- (d) no warranty or guarantee, or other assurance, has been made to me covering the results of the Services
- (e) knowing the risks involved I nevertheless chose to voluntarily request the Services.
Notwithstanding the foregoing (and by way of illustration only and not limitation) if any of the following apply to me or if I’m unsure for any reason, I hereby acknowledge the Company’s recommendation that I consult a medical physician before receiving Services.