Client Information

Date: * +

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of Birth: * +

Sex: *

Are you currently taking any medications? *

Yes

No

Please list any medications you are taking: *

Do you have any allergies: *

Yes

No

Please list any allergies (food, medications, etc.) *

Are you currently under a doctor's care? *

Yes

No

Please explain why you are under a doctor's care: *

Do you have a Primary Care Physician? *

Yes

No

Primary Care Physician Name: *

Primary Care Physician Phone Number: *

Emergency Contact Name *

Emergency Contact Phone Number *

Float Therapy

Please check if you have any of the following: *

FLOTATION THERAPY CONSENT

Flotation therapy consists of floating in Epsom salt water. This provides many benefits including relaxation and decreasing pain and inflammation.

Safety Instructions for Flotation Therapy:

Please do not wear any clothing during your float.
Please shower and remove any dirt, hair products, make up, lotion, or anything that would contaminate the environment.
Use the ear plugs to protect your ears.
Use the packaged oitment provided to cover any nicks or cuts before entering the float room (do not enter the float room with any open wounds).
You may end the session at any time if you experience any problems or anxiety.
When your session is over, please take another shower to remove the salt form your body and hair.
A person who is less than (18) years of age but greater than (14) years of age may not use flotation therapy without parental consent; parent/guardian must also be present during session

Contraindications to using Flotation Therapy:
Seizures, infection, pacemaker/serious heart condition, psychotic attacks, suicidal, open skin areas, first trimester of pregnancy, post-partum, less than 18 years of age (parental consent to treatment needed if greater than 14 years of age but less than 18 years of age), incontinence, under influence of alchol or drugs (particularly narcotics) or illegal substances, hair dyed within 7 days (or color that is still bleeding onto a towel when wet), and spray tan within 14 days (or color that is still bleeding onto a towel when wet), or tanning lotion/self-tanner within 7 days.

Risks to using Flotation Therapy:

Due to floating's non-invasive and weightless nature, it is one of the safest activities you can enjoy. Some first-time floaters can emerge from the tank feeling slightly nauseous, which can be a result of built-up stress leaving the body.

Cryotherapy and Infrared Sauna

Please check if you have any of the following: *

WHOLE BODY CRYOTHERAPY CONSENT

Whole body cryotherapy is the exposure of a person’s skin to temperatures of -150 to - 170 degrees Celsius (- 238 to – 274 degrees Fahrenheit) for a short time (3 minutes or less). At this extreme temperature, the body activates several mechanisms that have significant long-term medical and cosmetic benefits.

Skin:
The outer skin is briefly ‘frozen’, activating increased production of collagen in deeper layers of the skin (similar to lasers treatments of the face, where very hot temperatures are used). The skin regains elasticity and becomes smoother and 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 after several treatments. 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 5-8 hours after the procedure, causing the body to ‘burn’ 500 – 800 Kcal over the hours following the procedure. After several procedures, the increase in metabolic rate tends to last longer between treatments. Another ‘survival reaction’ to the extreme temperatures is the release of endorphins (hormones) that have analgesic and anti-inflammatory properties, and improve mood disorders. Cryotherapy has been studied for the successful treatment of medication resistant depressive disorders.

Clients furthermore experience a noticeable increase in libido, lending to the use of cryotherapy for ED and other sexual disorders.

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.

Immune System:
Cryotherapy improves the function of the immune system and decreases stress levels.

Safety Instructions for Whole Body Cryotherapy:

You must wear cotton or wool socks (and underwear in men) to avoid chilblain.
Treatments are limited to 3 minutes per session. Overexposure to the cold temperatures may cause chilblain
During treatment, you must avoid inhaling the nitrogen fumes; while non-toxic, they are devoid of oxygen and may cause fainting; keep your neck and head above the upper rim of the cryocabin as instructed;
You may end the procedure at any time if you experience any problems or anxiety;
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;
A person who is less than (18) years of age but greater than (14) years of age may not use whole body cryotherapy without parental consent; parent/guardian must also be present during session

Contraindications to using Whole Body Cryotherapy:
Pregnancy, severe Hypertension (blood pressure >=160/100), acute or recent myocardial infarction, unstable angina pectoris, arrhythmia, symptomatic cardiovascular disease, cardiac pacemaker, peripheral arterial occlusive disease, venous thrombosis, acute or recent cerebrovascular accident, uncontrolled seizures, Raynaud’s disease, fever, tumor disease, symptomatic lung disorders, bleeding disorders, severe anemia, infection, claustrophobia, cold allergy, less than 18 years of age (parental consent to treatment needed if greater than 14 years of age but less than 18 years of age), acute kidney and urinary tract diseases.

Risks of Whole Body Cryotherapy:
Fluctuations in blood pressure may briefly increase by up to 10 points systolically during treatment due to peripheral vasoconstriction. This effect should reverse after the end of the procedure, as peripheral circulation returns to normal. Allergic reaction to extreme cold (rare), claustrophobia, anxiety, and activation of some viral conditions (cold sores) etc. can occur due to stimulation of the immune system.

INFRARED SAUNA CONSENT

Using Far infrared saunas may put yourself at risk if you do not fully understand how to use the sauna. Far infrared saunas creating a cure for or treating any disease is neither implied nor should be inferred.

It is not recommended to attempt to self‑treat any disease with a far infrared sauna without direct supervision of a certified physician. If any of the items listed below apply to you, be certain to consult with your physician before using a far infrared sauna.

Hydration is a requirement as your body will sweat during sauna use. Drinking water is recommended before and after sauna use. Caffeinated beverages are not recommended as they dehydrate the body.

MEDICATIONS

Individuals who are using prescription drugs should seek the advice of their personal physician or a pharmacist for possible changes in the drugs effect when the body is exposed to Far infrared waves or elevated body temperature. Diuretics, barbiturates and beta-blockers may impair the body's natural heat loss mechanisms. Some over the counter drugs such as antihistamines may also cause the body to be more prone to heat stroke.

CARDIOVASCULAR CONDITIONS

Individuals with cardiovascular conditions or problems (hypertension I hypotension), congestive heart failure, impaired coronary circulation or those who are taking medications, which might affect blood pressure, should exercise extreme caution when exposed to prolonged heat. Heat stress increases cardiac output, blood flow, in an effort to transfer internal body heat to the outside environment via the skin (perspiration) and respiratory system. This takes place primarily due to major changes in the heart rate, which has the potential to increase by thirty (30) beats per minute for each degree increase in core body temperature.

ALCOHOL

Contrary to popular belief, it is not advisable to attempt to "Sweat Out" a hangover. Alcohol intoxication decreases a person's judgment; therefore, they may not realize it when the body has a negative reaction to high heat. Alcohol also increases the heart rate, which may be further increased by heat stress.

CHRONIC CONDITIONS / DISEASES ASSOCIATED WITH A REDUCED ABILITY TO SWEAT OR PERSPIRE

Parkinson's disease, Multiple Sclerosis, Central Nervous System Tumors, and Diabetes with neuropathy are conditions that are associated with impaired sweating.

HEMOPHILIACS / INDIVIDUALS PRONE TO BLEEDING

The use of Infrared should be avoided by anyone who is predisposed to bleeding.

FEVER, INSENSITIVITY TO HEAT, PREGNANCY

An individual that has a fever, insensitivity to heat, and pregnancy should not use the sauna.

JOINT INJURY

If you have a recent (acute) joint injury, it should not be heated for the first 48 hours after an injury or until the hot and swollen symptoms subside. If you have a joint or joints that are chronically hot and swollen, these joints may respond poorly to vigorous heating of any kind. Vigorous heating is strictly contraindicated in cases of enclosed infections be they dental, in joints, or in any other tissues.

IMPLANTS

Metal pins, rods, artificial joints or any other surgical implants generally reflect Far infrared waves and thus are not heated by this system, nevertheless you should consult your surgeon prior to using an Infrared Sauna. Certainly, the usage of an Infrared Sauna must be discontinued if you experience pain near any such implants. Silicone does absorb Far infrared energy. Implanted silicone or silicone prostheses for nose or ear replacement may be warmed by the Far infrared waves. Since silicone melts at over 200°C (392°F), it should not be adversely affected by the usage of an Infrared Sauna. It is still advised that you check with your surgeon and possibly a representative from the implant manufacturer to be certain.

PACEMAKER / DEFIBRILLATOR

The magnets used to assemble our units can interrupt the pacing and inhibit the output of pacemakers. Please discuss with your doctor the possible risks this may cause.

In the rare event, you experience pain and/or discomfort, immediately discontinue sauna use.

SERVICES WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

In consideration for using the flotation therapy, whole body cryotherapy, and infrared sauna (Equipment), I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS Odessa Cryotherapy, LLC, and its DBA HC Cryotherapy, its members, 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.
I understand that for Flotation Therapy I am entering a wet area and understand the risk of slipping and/or falling, and release Odessa Cryotherapy, LLC/HC Cryotherapy (DBA) and/or any other persons from any responsibility whatsoever.
I hereby confirm that no warranty or guarantee, or other assurance, has been made to me covering the results of the flotation therapy, whole body cryotherapy, and/or infrared sauna process, and I hereby relieve them 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.
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 may incur due to the use of Equipment by me.
It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assignees and personal representative, if I am not alive, and shall be deemed as a RELEASE, WAIVER, AND DISCHARGE of the above named RELEASEES. 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 TEXAS.
I understand that the RELEASEES will not be responsible for any medical costs associated with any injury.
I understand that Flotation Therapy and Infrared Sauna are provided for the basic purpose of relaxation, stress reduction, relief of muscular tension, and recovery from muscular tension. I understand that Whole Body Cryotherapy is provided for the basic purpose of relaxation, stress reduction, relief of muscular tension, recovery from muscular tension, and recovery from surgery, illness or injury. I further understand that Flotation Therapy, Whole Body Cryotherapy, and Infrared Sauna should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.
I understand that Flotation Therapy, Whole Body Cryotherapy, or Infrared Sauna technicians are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such.
Because Flotation Therapy, Whole Body Cryotherapy, and Infrared Sauna are contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the technician updated as to any changes in my medical profile and understand that there shall be no liability on the technician’s part should I forget to do so.

My signature below constitutes my acknowledgment that (1) I have read, understand, and fully agree to the foregoing CONSENT, (2) the proposed indoor flotation therapy, whole body cryotherapy, and infrared sauna process has been satisfactorily explained to me 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 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 understand the foregoing Waiver of Liability and Hold Harmless Agreement; I am at least eighteen (18) years of age and fully competent; I have given up considerable future legal rights; and I execute this Release freely, voluntarily, under no duress or threat of duress, without inducement, promise or guarantee being communicated to me.

Furthermore, I agree that I will comply with all instructions on the use of the flotation therapy, whole body cryotherapy, and infrared sauna devices 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.

CANCELLATION POLICY

We reserve the right to apply to your payment method half the regular service fee for services booked if you cancel your appointment within 1 hour of your appointment or do not show for your appointment.

Client Printed Name *

Date * +

Client Signature *

clear

Client Parent or Legal Guardian Name
(if client is >14 but <18 years old)

Date +

Signature of Client Parent or Legal Guardian of Client Name (if client is >14 but <18 years old)

clear

None	Age less than 14 years old
Cardiac pacemaker/serious heart condition	Claustrophobia
Fever (current)	First trimester of pregnancy
Hair color within 7 days	Incontinence
Infection (current)	Post Partum
Psychotic attacks	Spray tan within 14 days
Skin rash	Suicidal
Seizures	Tanning lotion/self-tanner within 7 days
Under the influence of alcohol or drugs	Other Serious illness or medical condition (please explain) Other Serious illness or medical condition (please explain)

None	Acute kidney and urinary tract diseases
Age less than 14 years old	Areas of numbness
Arrhythmia	Blood clots / bleeding disorder (venous thrombosis)
Cardiac pacemaker	Chronic pain
Claustrophobia	Cold allergy / sensitivity
Congestive heart failure	Currently Pregnant or think you might be Pregnant
Digestive disease	Fever (current)
Headaches	Heart attack
High blood pressure	Hypotension
Infectious disease	Joint disease
Joint or muscle injury	Migraines
Paralysis	Peripheral arterial occlusive disease
Raynaud's disease	Severe anemia
Skin disease	Stroke
Symptomatic lung disease	Symptomatic cardiovascular disease
Tumor disease	Seizures
Unstable angina	Weight >345 lbs
Other Serious illness or medical condition (please explain) Other Serious illness or medical condition (please explain)