Ice Bath - Health Intake Form

Ice Bath - Health Intake Form

Please complete the following information prior to undergoing your Ice Bath session
Full Name*

First NameLast Name
Date of Birth

DayMonthYear
Date
Phone Number*
E-mail
example@example.com
Contact Person*

First NameLast Name
Related*
Phone Number*

At Renessence, your well-being is our utmost priority. We strive to ensure not just high-quality service but also the safest environment for your treatments.

To uphold safety standards, we must be aware of any medical conditions or medications you're using. This information is held strictly confidential.

The following information is provided to assist you in determining if you are eligible to undergo an Ice Bath session.
CONTRAINDICATIONS AND CONSENT FORM

Ice baths, also known as cold water immersion therapy, involve immersing the body in cold water for a specific duration. Absolute contraindications are conditions or situations where Ice Baths should not be performed under any circumstances due to the potential for harm.

ABSOLUTE CONTRAINDICATIONS:

- Uncontrolled Hypertension (High Blood Pressure)

- Heart Conditions

- Pregnancy

- Cold Allergy

- Raynaud's Disease

- Circulatory Disorders

- Infections: Active infections, particularly those affecting the skin or respiratory system

- Open Wounds or Sores
Do you present any of the above contraindications? If YES, please indicate which one:*

GENERAL TERMS AND CONDITIONS

By proceeding, I confirm that you have read and approved the Terms & Conditions and House Rules by Renessence.
I Agree to Terms & Conditions and House Rules*

Yes