Auburndale_Sauna Waiver

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Medical History

PLEASE ANSWER THE FOLLOWING QUESTIONS
Have you ever used an infrared sauna before?*

YesNo
Are you pregnant?*

YesNo
If pregnant, how far along are you?
Are you taking any medications?*

YesNo
Diagnosed with any medical condition, such as Anhidrosis, that may limit or prevent your ability to sweat?*

YesNo
Do you have unstable angina?*

YesNo
Have you had a recent heart attack?*

YesNo
Do you have severe arterial disease?*

YesNo
Have you been diagnosed with any other medical condition?*

YesNo
If “yes”, please explain your condition
If you answered “yes” to any of the above questions; have you consulted with your medical provider about using a far infrared Sauna?

YesNo
It is always important to maintain proper hydration levels during far infrared therapy. Dehydration will actually increase carbohydrate utilization and cause less fat to be burned for energy. We highly recommend drinking a minimum of 4 oz. of water prior to entering the sauna and a minimum of 8 oz. of water after sauna use.
Please Read Carefully
ULTRA CRYO RECOVERY INFRARED SAUNA AGREEMENT/ ACKNOWLEDGMENT

1. The use of drugs, medication, or alcohol prior to or during the sauna session may lead to dizziness or unconsciousness.2. Please consult your physician if you are in doubt of your ability to use the far infrared for health reasons.3. No one under the age of 18 is permitted in the far infrared sauna unless accompanied by a supervising adult.4. Discontinue the use of the sauna if you feel light-headed, dizzy or heat exhausted.5. Sauna sessions should be limited to no more than 45 minutes and temperatures must stay below 150 degrees Fahrenheit.6. Water bottles are not permitted in the sauna.7. Clients using any medications must consult a physician or pharmacist prior to the use of the sauna.8. Pregnant women should consult their physician prior to the use of the sauna. Excessive body temperatures have a potential for causing fetaldamage during the early days of pregnancy.9. For safety reasons, there is a weight limit of no more than 300 lbs. per person in order to utilize sauna.I FURTHER UNDERSTAND THAT IT IS MY RESPONSIBILITY TO REQUEST, COMPLETE AND UPDATE A NEW INTAKE FORM ON MY FUTURE VISITS TO ULTRA CRYO & RECOVERY IF I EXPERIENCE A CHANGE TO MY CURRENT HEALTH CONDITIONS LISTED/DESCRIBED ABOVE. I UNDERSTAND AND VOLUNTARILY ACCEPT THE RISKS ASSOCIATED WITH THE FACIAL AND/OR ANY OTHER SERVICES, INCLUDING BUT NOT LIMITED TO: MASSAGE, FACIALS, SAUNA, etc. OR THE USE OF ANY OF THE LOCATION’S FACILITIES. EXCEPT WHERE PROHIBITED BY LAW; I ACKNOWLEDGE AND VOLUNTARILY ASSUME THE RISK OF INJURY, ACCIDENT OR DEATH WHICH MAY ARISE FROM THE USE OF A ULTRA CRYO RECOVERY INFRARED SAUNA, OR ANY OTHER PROGRAM, EVENT OR ACTIVITY. I AGREE ULTRA CRYO & RECOVERY WILL NOT BE LIABLE FOR DEATH OR ANY INJURY, INCLUDING, WITHOUT LIMITATION, PERSONAL, BODILY OR MENTAL INJURY, ECONOMIC LOSS OR ANY DAMAGE TO ME RESULTING FROM NEGLIGENCE, OTHER ACTS IN ULTRA CRYO & RECOVERY, ANYONE ACTING ON ULTRA CRYO & RECOVERY’S BEHALF, OR ANYONE USING THE SERVICES OF THE FACILITIES OF ULTRA CRYO & RECOVERY, TO THE FULLEST EXTENT PERMITTED BY LAW. THIS AGREEMENT TOGETHER WITH ULTRA CRYO & RECOVERY WELLNESS PLAN RULES AND REGULATIONS, CONSTITUTE THE ENTIRE AGREEMENT BETWEEN YOU AND US AND CANNOT BE AMENDED, EXCEPT IN WRITING BY BOTH PARTIES. MYSELF AND/OR ANY OF MY HEIRS, EXECUTORS, REPRESENTATIVES, OR ASSIGNEES HEREBY RELEASE MASSAGE GREEN SPA FROM ALL CLAIMS OR LIABILITIES FOR DEATH, PERSONAL INJURY OR PROPERTY LOSS OR DAMAGES OF ANY KIND SUSTAINED WHILE ON THE PREMISES, DURING THE USE OF THE ULTRA CRYO RECOVERY INFRARED SAUNA AND /OR FROM ANY ADVICE OR SERVICES PROVIDED BY AN EMPLOYEE, INDEPENDENT CONTRACTOR OR ANY REPRESENTATIVE OF MASSAGE GREEN SPA. I AGREE THAT THIS APPLICATION AND WAIVER IS IN EFFECT FOR ALL MASSAGES, FACIALS AND/OR ULTRA CRYO RECOVERY INFRARED SESSIONS OR ANY OTHER SERVICES, AND WILL NOT EXPIRE UNLESS SPECIFICALLY REQUESTED BY EITHER PARTY.
CONTRADICTIONS

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 infrared waves or elevated body temperature. Diuretics, barbiturates, and beta-blockers may impair the body’s natural heat loss mechanisms. Anticholinergics such as amitryptaline may inhibit sweating and can predispose individuals to heat rash or to a lesser extent, heat stroke. Some over-the-counter drugs, such as antihistamines, may also cause the body to be more prone to heat stroke.• Children: The core body temperature of children rises much faster than adults. This occurs due to a higher metabolic rate per body mass, limited circulatory adaptation to increased cardiac demands and the inability to regulate body temperature by sweating. When using with a child, operate at a lower temperature and for no more than 15 minutes at a time.• The Elderly: The ability to maintain core body temperature decreases with age. This is primarily due to circulatory conditions and decreased sweat gland function. The body must be able to activate its natural cooling processes in order to maintain core body temperature. When using with the elderly, operate at a lower temperature and for no more than 15 minutes at a time. Welcome - Confidential Property of Massage Green International Franchise Corporation (MGIF) – Updated -05-03-14 © 2014, Massage Green International Franchise Corp.• Cardiovascular Conditions: Individuals with cardiovascular conditions or problems (hypertension / hypo tension), congestive heart failure, impaired coronary circulation or those who are taking medications which might affect blood pressure should exercise caution when exposed to prolonged heat. Heat stress increases cardiac output and 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 / Alcohol Abuse: Contrary to popular belief, it is not advisable to attempt to “sweat out” a hangover. Alcohol intoxication decreases a person’s judgment; therefore, he/she may not realize when the body has a negative reaction to high heat. Alcohol also increases the heart rate, wh• ich may be further increased by heat stress.• Chronic Conditions / Diseases Associated With a Reduced Ability to Sweat or Perspire: 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 saunas should be avoided by anyone who is predisposed to bleeding.• Fever: An individual who has a fever should not use an infrared sauna until the fever subsides.• Insensitivity to Heat: An individual with insensitivity to heat should not use an infrared sauna.• Pregnancy: Pregnant women should consult a physician before using an infrared sauna.• Menstruation: Heating of the low back area of women during the menstrual period may temporarily increase their menstrual flow.• 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 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.• Implants: Metal pins, rods, artificial joints or any other surgical implants generally reflect infrared waves and thus are not heated by this system. Nevertheless, you should consult your physician prior to using an infrared sauna.• Pacemaker / Defibrillator: The magnets used to assemble our saunas can interrupt the pacing and inhibit the output of pacemakers. Please discuss with your doctor the possible risks this may cause.
It is the client's responsibility to let us know at any time if you are uncomfortable or want to stop the service.

NON-DISPARAGEMENT. Customer covenants and agrees that Customer shall not, at any time during the term of this agreement and thereafter, make statements or representations, or otherwise communicate, directly or indirectly, in writing, orally, or otherwise, or take any action which may, directly or indirectly, disparage Ultra Cryo & Recovery, Ultra IV & Therapeutics or any of its subsidiaries or affiliates or their respective officers, directors, employees, advisors, businesses or reputations. Notwithstanding the foregoing, nothing in this Agreement shall preclude Customer from making truthful statements that are required by applicable law, regulation, or legal process.
Client Name (Print Name)*
Date*
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FOR PARENTS/GUARDIANS OF PARTICIPANT OF MINOR AGE (UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releases from any and all liability incidents to my minor child’s involvement or participation in these programs as provided above, to the fullest extent permitted by law.
Signature of Parent/Guardian If Minor

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Medical History

Please Read Carefully

ULTRA CRYO RECOVERY INFRARED SAUNA AGREEMENT/ ACKNOWLEDGMENT

CONTRADICTIONS

FOR PARENTS/GUARDIANS OF PARTICIPANT OF MINOR AGE (UNDER AGE 18 AT TIME OF REGISTRATION)