CONSENT, RELEASE AND INDEMNITY AGREEMENT
Today’s Date:
|
Date of Birth:
|
Client or Parent/Guardian First Name:
|
Last Name:
|
Address:
|
Phone:
|
Email:
|
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
Minor Client Name: <CHILDFIRSTNAME> <CHILDLASTNAME> Date of Birth: <CHILDBIRTHDAY>
CHILLSCULPT, CHILLSKIN, WHOLE BODY CRYO AND LOCAL CRYO
ChillSculpt and ChillSkin treatments utilize the Pagani Cryo T- Shock device, using thermal shock to naturally destroy fat cells without any damage to the skin. The Cryo T-Shock breaks down fat cells, which your body naturally detoxifies from the treatment area through the bloodstream and then the lymphatic system in days and weeks following the treatment. Cryo T-Shock also helps reduce the appearance of cellulite, fine lines and wrinkles by stimulating collagen and elastin production while tightening muscles and skin. Cryo T-Shock is also beneficial for facial toning and lifting. Protocols will be discussed and or adjusted during consultation based on recommendations and clients’ needs.
The Cryo T-Shock should not be applied over inflamed, infected, or swollen areas of the skin, over/near cancerous areas or on clients undergoing active chemotherapy, used on clients who suffer from Liver or Kidney Disease, used on clients on dialysis, used on clients who are pregnant, used on clients who have had Botox treatments within 14 days or Filler treatments within 30 days, or used on clients who suffer from Severe Diabetes where sensation has been lost in the extremities.
I understand that results may vary depending on individual factors including but not limited to medical history, prior treatments of area being treated, skin type, patient compliance with pre/post care instructions and individual response to treatment. I understand that for purposes of fat/cellulite reduction/skin toning, I must maintain good dietary habits, have sufficient intake of water and participate in physical activity as well as comply with other items outlined during consultation.
I understand that any procedure involves risk. Risks may include redness, swelling, irritation, skin reaction, or increased heart rate. Some may experience delayed onset muscle soreness from treatments on the stomach due to unintentionally engaging the abdominals, which disappear later that same day.
Following any Cryo T-Shock Fat Freezing or Cellulite Reduction treatment the client understands that a 3 minute whole body Cryotherapy session or vigorous workout for at least thirty minutes is required the same day in order to facilitate lymphatic drainage and fat burning.
The benefits of whole body cryotherapy are vast and vary from person to person. Consult with your doctor or medical advisor if you have any questions as to whether Cryotherapy is right for you. Contraindications that will preclude you from participating in Cryotherapy include untreated High Blood Pressure, heart attack (within previous 6 months) or conditions related to heart surgery, congestive heart failure, COPD, chronic liver disease, unstable Angina Pectoris (chest pain), pacemaker, Valvular or Ischemic Heart Disease, peripheral Arterial Occlusive Disease, Deep Vein Thrombosis (DVT) or known circulatory dysfunction, acute febrile illness (such as flu), acute kidney and urinary tract diseases, severe anemia, cold allergenic phenomenon (known allergy to cold contactants), uncontrolled seizure disorders, bacterial and viral infections of the skin, wound healing disorders (open sores or discharging wound/skin conditions), alcohol or drug related inebriation, advanced Raynaud's Disease, polyneuropathies, pregnancy, vasculitis, hyperhidrosis (heavy perspiration), uncontrolled diabetes, or history of syncope/fainting/passing out
I have been honest and forthright about my medical history, and am healthy to use the device. I do not fall into any category warned of in this disclosure.
EXTRA-CORPOREAL SHOCKWAVE THERAPY
Extracorporeal Shockwave Therapy is a series of high-energy percussions to the affected area. The shockwave is a physical sound wave "shock", not an electric one. Treatment produces an inflammatory response. The body responds by increasing metabolic activity around the site of pain which stimulates and accelerates the healing process (promotes the remodeling of dysfunctional collagenous tissues, such as tendinopathies, trigger points, muscle strains, etc.). Shockwaves break down scar tissue and/or calcification. Transmission of pain is diminished through neurological mechanisms (inhibition of nociceptors). Approximately 5000 shocks are administered per treatment area (the duration of which is approximately 12 minutes). Some patients and/or conditions require more shocks and duration, depending on severity and chronicity (how long the condition or injury has existed).
It is a short treatment (usually five to twenty minutes) that may be fairly uncomfortable. However, most people are able to easily tolerate it. However, if you cannot tolerate it, adjustments on the machine can decrease the pressure you feel. There may or may not be immediate pain, but some discomfort may be experienced 2-4 hours after the treatment. In some cases it can last up to 48 hours and in very rare cases, the pain lasted up to 5 days. Some bruising and swelling can occur. The shockwave will trigger an inflammatory response, which is the body's natural process of healing. For this reason, do not use anti-inflammatory medications. Do not use ice. The pain should subside within 24 hours. Use Tylenol if necessary, provided you have no trouble with this medication. We recommend decreased activity for 48 hours following the treatment. Although the short-term effects alone are exceptional, the long-term benefits of this treatment may take up to 3-4 months. If after this time there has not been any marked improvement, you should see your doctor for further treatment options. Extracorporeal Shockwave Therapy is contraindicated for those suffering from the following: coagulation disorders, thrombosis, heart or circulatory patients, those using anticoagulants, especially Marcumar, Heparin, and Coumadin, Tumor diseases, carcinoma, cancer patients, pregnancy, polyneuropathy in the case of diabetes mellitus, acute inflammations / pus focus in the target area, children in growth, or cortisone therapy up to 6 weeks before first treatment. Side effects of treatment include: (These side effects generally abate after 5 to 10 days.) swelling, reddening, hematomas, petechiae, bruising, pain, skin lesions (especially after previous cortisone therapy). Pain can increase temporarily. Bruising and or swelling are also possible. We want you to be informed of all aspects. By signing the below, you acknowledge that you understand and accept the risks, benefits and costs of shockwave therapy, and consent to having this therapy administered
INFRARED SAUNA AND CHILL SLIM POD CONTRAINDICATIONS
If you have any questions regarding your current medical conditions and the use of the ChillRx Clearlight Far Infrared Sauna and/or Chill Slim Pod, please consult your medical doctor before use. Infrared Saunas creating a cure for or treating any disease is neither implied nor should it be inferred. In the rare event that you experience pain and/or discomfort while in the sauna or Chill Slim Pod, immediately discontinue use.
Seek permission from your doctor prior to use for the following: taking medications, under 12 years old, you are over the age of 70, cardiovascular conditions, or chronic conditions. Far infrared sauna and Chill Slim Pod use is contraindicated for people with following conditions: Pregnancy, Epilepsy, Active Cancer, Broken Bones or slipped disc, Infectious or contagious skin conditions, skin lesions, open abrasions and areas of inflammation or persistent erythema, Pacemakers or defibrillator, Hemophilia, Fever, Insensitivity to Heat, or Alcohol / Alcohol Abuse, Uncontrolled High Blood Pressure.
RAPID REBOOT PNEUMATIC COMPRESSION CONTRAINDICATIONS
Rapid Reboot dynamic compression technology is indicated for the temporary relief of minor muscle aches and pains and for the temporary increase in circulation to the treated areas in people who are in good health. The Rapid Reboot Compression Therapy System stimulates kneading and stroking of tissues by using an inflatable garment.
Please talk to your doctor first about the benefits of intermittent pneumatic compression for your specific needs. While Rapid Reboot is safe to use for a variety of applications, please consult your doctor if you know or suspect you may have the following: lesions or tumors in the treatment area, deep vein thrombosis (DVT), pulmonary embolism (blood clot) or edema, thrombophlebitis, inflammation of the skin (eg erysipelas, cellulitis), ischemic vascular disease, severe peripheral neuropathy, or related issues and complications, bone fractures or dislocation in the treatment area.
Acknowledgement:
I understand each person has a different response to each of the treatments detailed above. The risks, benefits, and possible results of each have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. I agree to have my photograph taken to document my results and will not be used for marketing unless agreed upon (see below).
Initial
1. PHYSICAL CAPABILITY. By signing this Agreement, I confirm that I am in good health, I do not have any of the Contraindications identified above, and I am not aware of any reason (medical, physical or otherwise) why I should not participate. I understand that abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, or medication, including but not limited to tranquilizers or blood pressure medication.
2. ATTIRE DURING WHOLE BODY CRYOTHERAPY SESSIONS. During each whole body cryotherapy session, I agree to wear the cotton socks, gloves and leather clogs provided by Chill Montclair Inc. I understand that all metal from the exterior of my body shall be removed prior to a session, including all large earrings, necklaces, bracelets, rings, body piercings, etc., and that any clothing that I wear during any such session must be completely dry. I understand that no lotions, oils, perfumes or any alcohol based products should be used prior to a session, and that if exercise before a session, I must be completely dry before using any machine or process.
3. NO REPRESENTATIONS. I understand that no representations or claims are made as to the therapeutic nature or other benefits of these sessions, and they are not intended to diagnose, treat, cure or prevent diseases, illnesses, imbalances or disorders. No results from participating in are guaranteed.
4. ASSUMPTION OF RISK; WAIVER OF LIABILITY. I acknowledge that Chill Montclair Inc. dba as ChillRx Cryotherapy Montclair has urged me to obtain a physical examination from my physician or medical provider prior to participating. I further acknowledge that my participation in a session and my use of the equipment, the companion therapies, and the facilities at Chill Montclair Inc. involve risk of injury to me, inclusive of major injury, disability and death, and I understand and voluntarily accept full responsibility for the risk of injury, disability, death or other loss arising out of or related to my participation in a session and my use of the Equipment, all companion therapies, and the facilities at Chill Montclair Inc. however caused. In consideration of my participation in a Session and my use of the Equipment and the facilities at Chill Montclair Inc. and in recognition of the possible dangers connected with such activities, I hereby knowingly and voluntarily waive any right or cause of action of any kind whatsoever that could arise as the result thereof. I further understand and acknowledge that Chill Montclair Inc. does not manufacture any equipment or products available at Chill Montclair Inc. but rather leases or purchases such equipment and products, and, therefore, I agree that neither Chill Montclair Inc. nor the Franchisor, nor any of the other Released Parties (as defined below), shall be held liable for any defects in such equipment or products.
5. INDEMNIFICATION; WAIVER AND RELEASE OF LIABILITY. I HEREBY AGREE THAT CHILL MONTCLAIR INC AND THE FRANCHISOR, AND EACH OF THEIR AGENTS, EMPLOYEES, OWNERS, MEMBERS, OFFICERS, REPRESENTATIVES, SHAREHOLDERS, INDEPENDENT CONTRACTORS, PARENTS, SUBSIDIARIES AND AFFILIATES (COLLECTIVELY, THE “RELEASED PARTIES”), WILL NOT BE LIABLE FOR: (A) ANY INJURY TO ME, INCLUDING, WITHOUT LIMITATION, PERSONAL, BODILY, OR MENTAL INJURY, DISABILITY, DEATH, ECONOMIC LOSS OR ANY DAMAGE TO ME RESULTING FROM THE ACTIVE OR PASSIVE NEGLIGENT CONDUCT OR OMISSION OF CHILL MONTCLAIR INC, THE FRANCHISOR OR ANY OF THE OTHER RELEASED PARTIES, WHETHER OR NOT RELATED TO MY PARTICIPATION IN A TREATMENT OR SESSION OR MY USE OF THE EQUIPMENT OR THE FACILITY, OR (B) ANY LOSS OF PROPERTY OR PROPERTY DAMAGE, INCLUDING ANY LOSS OR DAMAGE RESULTING FROM THE ACTIVE OR PASSIVE NEGLIGENT CONDUCT OR OMISSION OF CHILL MONTCLAIR INC, THE FRANCHISOR OR ANY OF THE OTHER RELEASED PARTIES. TO THE FULLEST EXTENT PERMITTED BY LAW, I HEREBY FOREVER WAIVE, RELEASE AND DISCHARGE CHILL MONTCLAIR INC, THE FRANCHISOR OR EACH OF THE OTHER RELEASED PARTIES FROM ANY AND ALL CLAIMS, DEMANDS, INJURIES, DAMAGES, ACTIONS OR CAUSES OF ACTION, WHETHER KNOWN OR UNKNOWN, ARISING OUT OF OR RELATED TO MY PARTICIPATION IN A TREATMENT OR SESSION, WHETHER DETAILED ABOVE OR NOT, OR MY USE OF THE EQUIPMENT OR THE FACILITY (COLLECTIVELY, THE “CLAIMS”), AND HEREBY AGREE TO DEFEND, INDEMNIFY AND HOLD HARMLESS CHILL MONTCLAIR INC, THE FRANCHISOR AND EACH OF THE OTHER RELEASED PARTIES FROM AND AGAINST ALL SUCH CLAIMS. I HEREBY WAIVE, RELEASE AND DISCHARGE ANY RIGHTS THAT I MAY OTHERWISE HAVE TO SUE CHILL MONTCLAIR INC, THE FRANCHISOR OR ANY OF THE OTHER RELEASED PARTIES.
I have read and fully understand the foregoing waiver and release of liability and my indemnification obligations as set forth herein. I understand the legal consequences of the waiver and release, as a full release of liability for injury, loss of property and/or property damage, and am fully aware that I have given up substantial rights by signing this Agreement. I agree that this Agreement, including this Section cannot be modified orally. I acknowledge and agree that I am signing this Agreement voluntarily without any inducement, assurance, or guarantee being made to me by Chill Montclair Inc and/or any person or entity on its behalf, and that I intend for my signature on this Agreement to operate as a complete and unconditional release of all liability to the greatest extent allowed by the laws of the State of New Jersey.
6. ENTIRE AGREEMENT; SEVERABILITY. I hereby acknowledge that neither Chill Montclair Inc. nor the Franchisor, nor any other person or entity, has made any written or oral representations, promises, or warranties that I have relied upon in entering into this Agreement, except as expressly set forth herein. This agreement contains the entire agreement between Chill Montclair Inc. and I, and replaces and supersedes any and all prior and/or written agreements. The terms of this Agreement shall continue from this date forward and shall apply each time I participate in any and all sessions at Chill Montclair Inc., without the need for me to re-execute this Agreement. If any portion of this Agreement is held invalid, the remainder shall not be affected and shall continue in full legal force and effect.
BY SIGNING THIS WAIVER OF LIABILITY AND MEDICAL RELEASE AND INDEMNIFICATION AGREEMENT (THIS “AGREEMENT”), AND IN CONSIDERATION OF BEING ABLE TO PARTICIPATE AT CHILL MONTCLAIR INC. DBA CHILLRx CRYOTHERAPY MONTCLAIR, A CHILLRX™ FRANCHISED BUSINESS, LOCATED AT 50 UPPER MONTCLAIR PLAZA, MONTCLAIR, NJ 07043 (THE “FACILITY”), I HEREBY AGREE AND CERTIFY TO CHILLRX FRANCHISING, LLC (THE “FRANCHISOR”) AND CHILL MONTCLAIR INC. I UNDERSTAND THAT CHILL MONTCLAIR INC. IS A LICENSED FRANCHISEE OF THE FRANCHISOR, AND THAT THE FRANCHISOR DOES NOT OWN OR OPERATE THE FACILITY. THE FACILITY IS OWNED AND OPERATED SOLELY BY CHILL MONTCLAIR INC. I ACKNOWLEDGE AND CERTIFY THAT I, , HAVE READ AND UNDERSTAND THE "CONSENT, RELEASE AND INDEMNITY AGREEMENT" FOR THIS TREATMENT, AND THAT I AM SIGNING IT VOLUNTARILY. SHOULD ANY PAIN OR DISCOMFORT OCCUR I WILL IMMEDIATELY NOTIFY THE CHILL MONTCLAIR INC. WELLNESS STAFF. I UNDERSTAND THAT I MUST BE ATLEAST 18 YRS OLD TO PARTICIPATE IN THIS TREATMENT. I UNDERSTAND THAT ALL SALES ARE FINAL AND REFUNDS ARE NOT PREMITTED.
Print Name:
Signature:
DATE:
PHOTO RELEASE
I may choose to give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Photographs or accompanying material will not contain my name or any other identifying information. I am aware that I will not be identified in the photos. ChillRx Cryotherapy Montclair agrees to get client approval prior to using any photographs or videos.
Yes, I agree to the above Photo Release.
No, I prefer to opt out.
Initial
CONSENT - COVID-19
Today’s Date:
I, , understand that I am opting to receive one or more services at Chill Montclair Inc., dba as ChillRx Cryotherapy Montclair.
I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact and accordingly, federal and state health agencies recommend social distancing and other measures to minimize spread.
I recognize that the owner and staff at ChillRx Cryotherapy are closely monitoring this situation and have put in place reasonable measures targeted to reduce the spread of COVID-19. Given the nature of the virus, however, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with services at ChillRx Cryotherapy.
Accordingly, I acknowledge and assume the risk of becoming infected with COVID-19 by using ChillRx Cryotherapy’s services, and I give my express permission for the ChillRx Cryotherapy staff to provide me with these services.
I understand that possible exposure to COVID-19 while at ChillRx Cryotherapy may result in any of the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, intensive care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described in this Consent.
I understand that the staff at ChillRx Cryotherapy have asked or will ask me about my current and prior health status regarding illness and Covid19 exposure. I have been truthful and forthcoming with my answers and do not know of any risks that I am exposing the ChillRx Cryotherapy staff or other clients to.
I understand all the potential risks, including, but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with the services I desire. I acknowledge that I have been offered a copy of this consent form. This consent form will be binding for all future services that I receive at ChillRx Cryotherapy.
I UNDERSTAND THE EXPLANATION AND HAVE NO FURTHER QUESTIONS AND AGREE WITH THE ABOVE.
Client Name:
Signature of Client Below: