Chillology ATL LLC Intake & Waiver Form

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Have you ever had Targeted Cryotherapy Before? If yes, when?
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HEALTH INFORMATION & CONTRAINDICATIONS

Are you currently taking any medications (Including any vitamins or supplements)? If so, please list below.

GENERAL HEALTH CONDITIONS

Do you have acute febrile respiratory (flu like respiratory conditions)?Do you have cold allergenic phenomenon (known allergy to cold)?Are you pregnant?

Are you currently receiving physical therapy?If yes, check all that apply:

Please tell us what piqued your interest in cryotherapy and what your expectations are for the treatment:

WAIVER OF LIABILITY & MEDICAL RELEASE AND INDEMNIFICATION AGREEMENT

Pain management, Skin Condition Treatment (Parethesis-Psorisis, Eczema, Acne), Cryofacials, Cryoslimming (Fat Freeze), with Chillology ATL cryo-aesthetic device causes thermal shock to the affected area due to its ability to spray C02 at -110 °F under 50bar pressure, cooling the treatment area locally. The affected area will be exposed to 90 second blasts using a freeze thaw technique. The treatments are powered by cryostimulation – a medical treatment used for immediate pain relief to help improve mobility and aid recovery by freezing within the temperature range of +5 to 24 °F. The cold treatment encourages the release of hormones including adrenaline and B Endorphins which are powerful natural pain killers. Cryostimulation also reduces systemic inflammation and muscle tension. Stimulates immediate improvement in blood flow and lymphatic drainage.

ABSOLUTE CONTRAINDICATIONS (PARTICIPATION IN COLD THERAPY SESSION NOT ALLOWED):
• Cold allergenic phenomenon (known allergy to cold)
• Bacterial and viral infections of the skin, wound healing disorders (open sores or discharging)
• Wound/skin conditions
• Active cancer or chemotherapy

This list may not be all inclusive, so if you have any particular health problem which you believe would preclude you from participating please check with your physician before participating.

ABOUT THE TREATMENT:
• Please ensure that you are completely dry. You are about to be exposed to extremely cold temperatures and therefore you cannot have any water on your body. This includes perspiration and lotions.
• Treatments are limited to 3 minutes per area.
• You may end the procedure at any time if you experience any problems or anxiety.
• A person who is less than (18) years of age will not be serviced without parental consent.

Recommended Treatments:
• Minimum of five sessions are required for effective results
• Effective outcome requires treatment to be carried out 2-7 days apart
• Further top up treatments may be required for long term effective management.

RISKS OF CRYOTHERAPY

Side Effects/Risks:
• Treatment may not be successful
• Frostnip - Frostnip generally does not lead to permanent damage because only the top layers of skin are involved. However, frostnip can lead to long-term sensitivity to heat and cold.

In consideration for being permitted by Chillology ATL LLC to participate in a Cryotherapy activity, I hereby waive any and all claims and damages for personal injury or death which may occur as a result of my participation. I understand and agree that:
1. This release is intended to discharge in advance Chillology ATL LLC, its officers, employees and agents from and against all liability arising out of or connected in any way with my participation in these activities;
2. I hereby confirm that no warranty or guarantee, or other assurance, has been made to me covering the results of the cryo process, and I hereby release, indemnify and hold harmless Chillology ATL LLC, its officers, employees and agents, 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. Participation may involve risk of physical injury and may result not only as a result of my actions, negligence or inaction, but also from the action, negligence or inaction of others, including their owners, officers, employees or agents, may result from the conditions of the facilities or areas where such activities are being conducted;
4. Knowing the risks involved and the contraindications related, I nevertheless choose voluntarily to request permission to participate;
5. I will indemnify and hold harmless Chillology ATL LLC, its owners, employees and agents from any loss, liability, damage, cost or expense, including litigation of any form, arising out of or connected in any manner with my participation in such activities;
6. I am in good health and have no physical condition expressed in the ‘contraindications’ or otherwise which would preclude me from safely participating in such activities; I have been advised that if I suffer from any medical condition or illness whatsoever, I am NOT TO receive targeted cryotherapy treatments without my doctor’s written permission.
7. I understand and agree that this release is intended to be as broad and inclusive as permitted under Georgia law and that if any portion of this Liability, Medical Release and Indemnification Agreement should be determined to be invalid, it is my intent that the remaining provisions shall continue in full force and effect.

IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read and understand the foregoing and the proposed cryotherapy process has been satisfactorily explained to me and I have all of the information I desire. I am at least eighteen (18) years of age and fully competent; and I execute this document for full, adequate, and complete consideration fully intending to be bound by same. Furthermore, I agree that I will comply with all instructions on the use of targeted cryotherapy and that I am using these services at my own risk.

FOR MINORS:

I HAVE READ AND UNDERSTAND THIS AGREEMENT AND I AM AWARE THAT BY SIGNING THIS AGREEMENT I AM WAIVING CERTAIN SUBSTANTIAL LEGAL RIGHTS WHICH MY MINOR CHILD/WARD, HIS/HER HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS AND ASSIGNS AND I AND/OR MY MINOR CHILD/WARD MAY HAVE AGAINST THE RELEASEES.

I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A POTENTIAL CONFLICT BETWEEN MYSELF, MY MINOR CHILD, AND CHILLOLOGY ATL LLC. I VOLUNTARILY AGREE TEACH OF THE TERMS AND PROVISIONS HEREIN AND SIGN THIS OF MY OWN FREE WILL.

PRIVACY POLICY

Chillology ATL LLC is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you, unless you notify us in writing that you do not want us to contact you by e-mail or text message. You can unsubscribe from our electronic communications at any time. For more information on our privacy practices, please review our Privacy Policy which is incorporated here by reference.

Photographs:

By signing this waiver, you hereby grant the releasee permission to use photographs in any of the following:Web-based publications Print Advertisements Organization Bulletin. I hereby affirm that such release to the releasee does not constitute any form of compensation, including royalties arising from the photographs, to my benefit.

I understand and agree that photographs in the possession of the releasee shall become the property of the releasee. The use and publication of the photographs however, shall conform to my rights as a subject of said photographs.

I hereby waive my right to inspect of approve the photographs by which my likeness appears.

I hereby hold harmless, release, and forever discharge the from all claims, demands, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

If in the future, you wish to withdraw this consent you have the right to do so at any time by letting us know in writing. Your choice of consent level will not affect your treatment in any way.

Client Name*

First NameLast Name

Parent or Guardian’s Name

First NameLast Name

Signature*

Date