PERSONAL INFO AND CONSENT PLEASE READ THIS ENTIRE FORM. INITIAL AND SIGN WHERE REQUESTED. Thank you. Name DOB First Session Date Address City State Zip Cell Phone Cell Phone Carrier E-Mail Occupation For your appointment reminders, do you prefer to be notified by: Text SMS, Email, Both In Case of Emergency Relationship Phone How did you hear about us? What brings you to iceland Cryo? Please circle all that apply: Acne; facial or body An accident Athletic performance and recovery Autoimmune disorders Blood or lymphatic disorders Cellulitis Chronic pain or inflammation Depression or anxiety Experience the extreme cold Fatigue Fibromyalgia pain Immune system deficiencies Injury, scar or surgery Jet-lag or hangover Libido and sex drive Muscle soreness Osteoarthritis pain Psoriasis, dermatitis, eczema Restful sleep problems Rheumatoid arthritis pain Skin blemishes or age spots Sun burn Weight loss Anything else not listed? BELOW FOR OFFICE USE BP / Pulse Session Time Leg Temp. Copyright iceland Cryo 2014 Page 1
We will start with WHO SHOULD NOT USE Cryosauna Therapy. DO NOT USE CRYOSAUNA THERAPY IF YOU HAVE ANY OF THE FOLLOWING: Acute febrile respiratory (Flu like respiratory conditions) Acute kidney and urinary tract diseases Alcohol and drug abuse Asthma Bacterial and viral infections of the skin Chronic liver disease Cold Allergenic Phenomenon (known allergy to cold contactants) Congestive Heart Failure Decompensating diseases (edema) of the cardiovascular and respiratory system; Deep Vein Thrombosis (DVT) or known circulatory dysfunction Heart attack within previous 6 months Heavy consumerist diseases (abnormal bleeding) Hyperhidrosis heavy perspiration Incontinence Ischemic heart disease Pacemaker Peripheral Arterial Occlusive Disease Polyneuropathies Pregnancy over 4 months Raynaud s disease Recent heart surgery Seizure disorders Severe Anemia Unstable Angina Pectoris Untreated Hypertension Valvular heart disease Vasculitis Wound healing disorders (open sores or discharging wound/skin conditions) SPECIAL NOTES TO THE ABOVE: PREGNANCY (If you have any inclinations that you may be pregnant, do not use the Cryosauna, please have it verified first) PACEMAKER (Or any electronic devise implanted inside your body. Please provide your doctor s note Cryosauna is OK for you) UNCONTROLLED HIGH BLOOD PRESSURE (160/100 see a doctor ASAP, this is life threatening) ASTHMA or BREATING DISORDERS BUZZED (We reserve the right to refuse service to anyone who looks high or drunk) OTHER MEDICAL CONDITIONS (It s always best to check with your doctor show the doctor our site and let them decide) At iceland Cryo, we are not doctors and we are not able to give medical advice or judge the medical conditions of clients using our cryosauna machine. If you are not in good health or have doubts about your health, please seek the advice of a qualified doctor who is familiar with the Cryosauna or Whole Body Cryotherapy since many American doctors have no clue what this is, ask them to find out before they write this off Cryotherapy has been proven to increase the quality of life of many people. If you have the following Conditions you should not use Cryotherapy: Pregnancy, Severe Hypertension (BP> 160/100), Acute or recent myocardial infarction, Asthma, Unstable angina pectoris, Arrhythmia, Symptomatic cardiovascular disease, Cardiac pacemaker, Peripheral arterial occlusive disease, Cold-activated asthma, Venous thrombosis, Acute or recent cerebrovascular accident, Uncontrolled seizures, Raynaud s Syndrome, Fever, Cryoglobulinemia, Cryofibriongenemia, Agammaglobulinemia, Active Cancer, DVT, Acute infections, Certain medications (antipsychotic, alcohol), Cold intolerance and/or allergy to cold, Damaged skin, Claustrophobia, Hypothyroidism, Symptomatic lung disorders, Bleeding disorders, Severe anemia, Infection, Acute kidney and urinary tract diseases, Age less than 18 years (parental presence to treatment needed). Precautions Risks of whole body cryotherapy: Fluctuations in blood pressure (in whole body cryotherapy, due to peripheral vasoconstriction, blood pressure may briefly increase by up to 10 points systolically during treatment), Allergic reaction to extreme cold, Frostbite. So in a nutshell if any of these apply to you, please seek the advice of your doctor or do not use the cryosauna. Copyright iceland Cryo 2014 Page 2
Whole Body Cryotherapy The Cryosauna With Whole Body Cryotherapy (WBC) the body is exposed to ultra-low temperatures (-220 Fahrenheit), triggering a systemic anti-inflammatory response. This modality was first utilized in Japan in 1978 to treat rheumatoid arthritis. Studies conducted over the last three decades have established WBC as a powerful treatment for inflammatory disorders and injuries. The accelerated production of collagen can improve skin elasticity and texture, slowing skin aging and the appearance of cellulite. This varies from client to client. Please note: Many procedures and progress vary from client to client. Of course, people come in all shapes and sizes it is not so much in the difference of body size one has, as it is in the biology and gene makeup of the individual. The individual s own body chemistry, their life style; foods and drinks and medications, all contribute to variations in how a particular individual body will respond to this type of therapy. So for some, 10 sessions may produce desired results, whereas others may take only 5 or up to 20 sessions. Simply put there are no set parameters of how an individual s body will react to cryosauna therapy, and as providers of such cryosauna therapy we cannot set parameters of when said therapy will be of significant benefit to an individual or guaranty any beneficial results. As a team effort with you and us, we will strive to find the best session formula for you. Weight Loss: WBC boosts the body s metabolic rate, accelerating weight loss outcomes. This change in metabolism causes the body to increase heat production over the next 10 to 12 hours which results in burning 500 to 800 extra calories per session. Musculoskeletal: The anti-inflammatory and analgesic properties of cryotherapy can drastically improve joint disorders such as rheumatoid and osteoarthritis. Athletes are using whole body cryotherapy to recover from injuries and improve their performance. Skin: Skin exposure to temperatures below 220 degrees Fahrenheit triggers the systemic release of anti-inflammatory cytokines, and decreases circulating pro-inflammatory cytokines. This internal response decreases inflammation in all areas of the body. The rapid cooling of the skin activates the production of collagen. The skin regains elasticity and becomes smoother and more even-toned, significantly improving conditions such as cellulite and skin aging. Skin vessels and capillaries undergo severe vasoconstriction (to keep the core temperature from dropping), followed by vasodilation after the procedure. Toxins and other stored deposits are flushed out of the layers of the skin and blood perfusion is improved. Clients have reported that after just one session they saw their urine turn orange the next day do not be alarmed, this is a natural after effect of the cryotherapy whereby the toxins in the body begin to be flushed away. The anti-inflammatory properties of cryotherapy are also used to treat chronic skin conditions such as psoriasis and dermatitis. Endocrine: The extreme cold exposure causes to the body to turn up its metabolic rate in order to produce heat. This effect lasts for hours to days after the procedure, causing the body to burn up to 800 calories following the procedure. After several procedures, the increase in metabolic rate tends to last longer. Another survival reaction to the extreme temperatures is the release of endorphins (hormones) that have analgesic and anti-inflammatory properties, and improve mood disorders. WBC has been studied for the successful treatment of medication resistant depressive disorders. Immune System: Cryotherapy improves the function of the immune system and decreases stress levels. The release of endorphins causes a pleasant euphoric feeling. Copyright iceland Cryo 2014 Page 3
Safety Instructions for Whole Body Cryotherapy: The world s coldest place is Vostok Station, Antarctica with a record low temperature of MINUS 128.6 degrees F! You will be inside a Juka cryosauna chamber for up to 3 minutes almost naked and the temperatures will be around MINUS 220degrees Fahrenheit! Sounds crazy doesn t it? The Mile High Club has nothing on the MINUS 220 CLUB! If you can survive such cold temps you can survive anything in the world!!! And the benefits will be astounding! Actually this ultra-cold experience is rather pleasant, and many say it is additive. You decide. 1. You must wear DRY cotton socks, which we will provide you (and cotton underwear for men) to avoid chilblain or frostbite. Cryotherapy works best by exposing as much naked skin area during treatments. If you have sensitive nipples (as in Surfer s Nipple or Jogger s Nipple both men and women) it is advisable to wear protection on those areas we have band aids to cover up just in case. 2. Do not arrive for your cryosauna treatment while jogging or biking or just worked out to our office you will be sweaty and wet. But if you insist on doing so please arrive 20 minutes prior to your appointment time so that your body can recover and cool down naturally. Cryotherapy uses dry ultra-cold temperatures, and anything wet could cause frostbite. SO NOT WET SOCKS, NO WET UNDERWEAR, OR ANYTHING WET. YOU MUST BE DRY, DRY, DRY. 3. Treatments are limited to a maximum of 3 minutes per session. 4. During treatment, you must avoid inhaling the nitrogen fumes; while non-toxic, they are devoid of oxygen and may cause fainting. 5. You may end the procedure at any time if you experience any problems or anxiety just tell the operator you ve had enough the machine will immediately be stopped but be careful opening the door since if you have been lifted your next step might be a long one down, it is advisable to wait a few seconds while the lift brings you down. 6. 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, Cold sores if you are taking any medications or have cold related problems, please check with your doctor first to make sure you won t have any adverse skin reactions to the ultra-cold temperatures. 7. A person who is less than (18) years of age may use whole body cryotherapy with a parent or guardian present, and signing for them. 8. If you have metal piercings, rings or jewelry attached to your body in locations below your neck it is definitely advisable to remove such items prior to your arrival for cryotherapy. 9. While inside the Cryosauna it is best to turn in a circle so that the body receives equal amounts of cold. 10. Photography is allowed and encouraged. With your permission, you can be photographed inside the Cryosauna and become an official member of the iceland Cryo Polar Bear Club. What to Bring and Wear For Whole Body Cryotherapy: This is easy. WBC works best when the greatest amount of skin is exposed to the ultra-cold cryosauna. Wear as little as you can and still be comfortable. Please ensure your birthday suit is dry and clean. We will provide socks, leg warmers, boots, gloves and body towel. For men, wear cotton underwear. For women, if you wish, wear a sports bra but no underwire bras...it has metal in it and can cause freeze burns on the last place you want. The best advice for first timers wear what you wear to the beach. Bathing suit bottoms for men and Bikinis for the ladies. Just make sure there are no metal zippers, metal buttons or such on your outfit. Earrings, glasses, small necklaces are OK to wear inside the cryosauna. If you have expensive jewelry, it s best to leave it in your car. We have change rooms where you can change clothes. If you prefer you may bring a robe or a big towel. In group sessions we will have one person following another into the cryosauna. So wear what you are comfortable within a group setting. Many people wear their towels into the Cryosauna and remove them once the door is closed. When the session is finished the towel goes back on and the door opens up all very private and discrete. Copyright iceland Cryo 2014 Page 4
Waiver of Liability, Release and hold Harmless Agreement: 1. In consideration for using the cryotherapy treatments/machines (Equipment), I hereby release, waive, discharge, and hold harmless Auksas, LLC dba iceland Cryo in Tequesta, Florida, its officers, servants, agents, 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 or anything in the iceland Cryo office. 2. I hereby confirm that no warranty or guarantee, or other assurance, has been made to me covering the results of the cryotherapy treatments, and I hereby relieve releasees 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 I 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 me, my spouse and the members of my family and spouse, if I am not alive, and my heirs, assignees and personal representative, and shall be deemed as a release, waiver, and discharge of the above named releases. 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 Florida and venue shall be exclusively in Palm Beach County, Florida. 5. I understand that the releasees will not be responsible for any medical or incidental costs associated with any injury I may sustain due to the use of the Cryosauna and/or any of the facilities at the iceland Cryo office. 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 by reading this form that if I suffer from any medical condition or illness whatsoever, I am not to use the Equipment without my doctor s written permission. 7. I understand that I take full responsibility for any willful or accidental damage I or my guests or my invitees may commit or cause while at the iceland Cryo office and I will pay immediate restitution to the owners for any and all damages. 8. Physical and mental conditions discussed herein and on www.icelandcryo.com are representative of commonly known and studied applications and symptoms, but Whole Body Cryotherapy aka Cryosauna is not guaranteed to diagnose or cure specific diseases. 9. I confirm that I have received no medical advice from Releasees. I also understand, acknowledge and accept that I may receive no beneficial results from my use of the Cryosauna. 10. In the event of any litigation arising out of the terms of this agreement, the prevailing party in such litigation shall be entitled to recover all reasonable attorney s fees and costs incurred against the non-prevailing party, including fees and costs incurred on appeal. My signature below constitutes my acknowledgment that (1) I have read, understand, and fully agree to the foregoing consent, (2) the proposed cryotherapy process has been satisfactorily explained to me as noted above 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 have read the instructions for proper use of the facilities and cryosauna machine 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 fully understand the foregoing Waiver of Liability; Release and Hold Harmless Agreement, all Client Consent forms, and 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. I have also acknowledge that if anything in this agreement is not understood that I will consult with an attorney before signing this agreement. Furthermore, I agree that I will comply with all instructions on the use of the cryotherapy device 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. Participant s Printed Name Signature Date If Participant is Under 18: Name of Parent or Legal Guardian Signature Date Copyright iceland Cryo 2014 Page 5