Release Form

NEW CLIENT INTAKE FORM & CONSENT

Localized High Impact Cryotherapy Services

 

To enable us to ensure your comfort and safety in all services we provide, please take time to carefully read this form and answer ALL QUESTIONS to your best ability.

All provided information is CONFIDENTIAL and protected – we will never share it with any 3rd parties, unless required by law.

 

Introduction. What is localized high impact cryotherapy

For localized cryotherapy services, we use one of the newest and most effective technologies on the market.

The procedure includes spraying the treatment area with dry vapor of carbon dioxide (CO2), as cold as -108° F, under pressure as high as 50 bar, in short 30 to 90-second increments per treatment area. The combination of precise targeting, extremely low temperatures, and strength of the flow results in more rapid and deeper cooling of the affected tissue, producing better results faster.

This technique is not considered a medical treatment, but rapid cooling of the skin and underlying tissue can be used for pain management, stimulation of cell regeneration, tightening and brightening of the skin, anti-aging facials, and reduction of stubborn fat deposits and cellulite, amongst other effects.

Thermal shock improves blood flow in the treatment area and helps reduce inflammation. If applied to fat cells that are more sensitive to cold than any other cell in the body, cooling triggers a process called cryolipolysis and results in apoptosis – controlled permanent destruction of subcutaneous fat tissue.

Localized cryotherapy is safe for most people, but some contraindications have been identified and negative side effects are possible. Familiarizing yourself with the below information will help you avoid unwanted consequences.

Having any of the contraindications described in this document will require you to use discretion for your own well-being.

Cold applications can feel slightly uncomfortable and leave the skin pink for a short period following the session while the skin temperature is returning to normal, but there is no damage and no recovery required. In case of experiencing any burning sensation, pain, or significant discomfort at any time during our treatments, we strongly advise you to terminate the session immediately upon your own volition.

Localized high impact cryotherapy for pain management

We use a high-pressure flow of gasiform CO2 to lower the tissue temperature in the treated area. This process, called cryostimulation, causes constriction of the blood vessels in response to cold, followed by dilation and improved blood flow post-treatment, reducing inflammation and swelling and stimulating release of hormones like noradrenaline and Beta-Endorphins which are powerful natural pain killers. Applications include athletic recovery, recovery from soft tissue, muscle, tendon, or overuse injuries or surgery, and painful motion-limiting medical conditions.

This treatment does not impose health risks but should NOT be applied to highly sensitive skin or open wounds and should be avoided in case of cold allergies or any other cold-induced condition.

Localized high impact cryotherapy for fat freezing/ body sculpting

In this process, we use a phenomenon called cryolipolysis. Cooling the problem areas to the point when subcutaneous fat cells that are very sensitive to low temperatures get damaged and die leads to gradual slimming. Post-treatment, the body uses the lymphatic system to permanently expel the damaged cells.  

Because of the strain that the need to eliminate the cellular debris puts on the body, you should NOT do fat freezing treatments if you are pregnant, undergoing dialysis, having only one kidney or any type of kidney or liver disease, or impaired circulatory system. Being oversensitive or allergic to cold, having active cancer, or going through chemotherapy are also contraindicated.

High impact cryo facials

Cold applied to the face, neck, or decolletage causes blood vessels to constrict, then dilate, improving circulation and making the skin look firmer and better toned. The process also soothes inflammation, helps fight bacterial infections like acne and stimulates collagen production that has anti-aging effect.

You should NOT use cold if you are cold-intolerant or your skin is highly sensitized by sun or treatments like chemical peels. You should take a 2-week break after procedures like Botox or fillers.

In consideration of using the localized cryotherapy services offered by Lifestyle Broker, LLC and by filling out and signing this Intake Form prior to or during your first visit, you have acknowledged the following:

You have been truthful in disclosing your current health condition, as well as past health-related events, including but not limited the ones listed as definite contraindications.

You understand that the services provided by Lifestyle Broker, LLC, although they may have certain health benefits, have been designed to enhance health, appearance and vitality in generally healthy individuals. You have been advised that all services have contraindications and that you should ONLY use any treatments if you either don’t have the related risks or have discussed these risks with your doctor and obtained their written consent.

You recognize the importance of informing Lifestyle Broker, LLC personnel about any changes in your health condition, including pregnancy, as they may compromise effectiveness and/or safety of the services you will be receiving.

You are aware of the need to postpone your appointments with Lifestyle Broker, LLC if you are feeling sick and have symptoms like fever, congestion, cough, shortness of breath, chest pain, dizziness, nausea, rash, or if you get an acute infection of any kind. The Lifestyle Broker, LLC cancellation requirements and package expiration dates still apply.

You have been informed that results, especially when it comes to fat loss, cellulite, or aging, are not always immediate, and some benefits will continue to develop over weeks, or even months, post-treatment. Because your body and lifestyle are unique, so will be your progress. In some cases, treatment may not be successful, especially if you fail to follow treatment number and frequency recommendations given to you by Lifestyle Broker, LLC staff. Commitment to minimum 5 sessions followed by a proper maintenance protocol is paramount for success.

You consent to commit to promptly following all safety and other behaviour- and treatment-related instructions posted through the studio or given to you by Lifestyle Broker, LLC personnel.

You accept the responsibility to immediately inform Lifestyle Broker, LLC if you feel discomfort or experience any adverse effects from any treatment that you are undergoing, as they may indicate the need to discontinue the service.

You confirm that you have been explained and understand the administration of the localized high impact cryotherapy services provided by Lifestyle Broker, LLC, including possible adverse reactions, side effects, or complications. They are rare, but, when extreme cold is involved, minor frostbites may occur and may lead to long-term sensitivity of the affected area to heat or cold post-event.  

Based on the above, YOU VOLUNTARILY ASSUME FULL RESPONSIBILITY for engaging in the said services and AGREE TO INDEMNIFY AND HOLD Lifestyle Broker, LLC HARMLESS from any consequences and related costs that may incur due to your use of any of the treatments.

You also acknowledge that you have been given no warranty or guarantee of any particular results. You understand that the outcome depends not only on the treatments, but also diet, lifestyle choices and numerous other factors outside Lifestyle Broker, LLC’s control.

Except for pain management, clinical photographs play a key role in monitoring your progress over the weeks of treatment and education of our staff. They also help inform equipment suppliers in the process of continuous development of new applications and better technologies.

Different types of consent are required according to the way in which clinical images will be used. Please CHOOSE ONE of the below. If you do not fully understand what each option implies, please ask. Please note that we must take photographs to monitor your progress; so, at least the lowest level of consent (case notes) is REQUIRED.

Service Terms & Conditions

In consideration of using LIFESTYLE BROKER, LLC wellness services and by filling out and signing the Interest Form during your first visit, you have acknowledged the following:

You have been truthful in disclosing your current health condition, as well as past health-related events, including but not limited to major surgeries, organ transplants, artificial joints, metal screws or implants in your body, heart attacks, strokes, seizures, sudden loss of consciousness, or cancer treatments.

You understand that the wellness services provided by LIFESTYLE BROKER, LLC, although they may have certain health benefits, have been designed to enhance fitness, appearance, and vitality in generally healthy individuals. You have been advised that all services have contraindications and that you should ONLY use any treatments if you either don’t have the related risks or have discussed these risks with your doctor and obtained their written consent.

You recognize the importance of informing LIFESTYLE BROKER, LLC about any new diagnosis, medical treatments or drugs that you are prescribed, as they may compromise effectiveness and/or safety of the wellness services you will be receiving from LIFESTYLE BROKER, LLC. You must also inform LIFESTYLE BROKER, LLC personnel if you are trying to conceive, are pregnant or breastfeeding, as some treatments may be contraindicated during these periods.

You are aware of the need to postpone your appointments with LIFESTYLE BROKER, LLC if you are feeling sick and have symptoms like fever, congestion, cough, shortness of breath, chest pain, dizziness, nausea, rash, or if you get an acute infection of any kind. The LIFESTYLE BROKER, LLC cancellation requirements and package expiration dates still apply.

You agree to consult LIFESTYLE BROKER, LLC and follow its advice regarding possible temporary suspension of treatments in case of bleeding (including menstruation), burns, cuts, sprains, dislocated joints, or allergy flair-ups.

You commit to promptly following all safety and other behavior- and treatment-related instructions posted through the studio or given to you by LIFESTYLE BROKER, LLC staff members.

You accept the responsibility to immediately inform a LIFESTYLE BROKER, LLC staff member if you feel discomfort or experience any adverse effects from any treatment that you are undergoing, as they may indicate the need to discontinue the service.

You confirm that you have been explained and understand the administration of the services provided by LIFESTYLE BROKER, LLC, including possible adverse reactions, side effects, or complications that may arise from your failure to disclose risks or to follow instructions. Therefore, YOU VOLUNTARILY ASSUME FULL RESPONSIBILITY for engaging in the said services and AGREE TO INDEMNIFY AND HOLD LIFESTYLE BROKER, LLC HARMLESS from any health consequences and related costs that may incur due to your use of any of its wellness treatments.

You also acknowledge that no warranty or guarantee of any particular results has been made to you regarding these wellness services. You understand that any result is achieved in combination of not only treatments, but also diet, lifestyle choices and numerous other factors outside LIFESTYLE BROKER, LLC’s control.

By signing the Interest Form, you have also accepted the General Terms and Service Conditions that include the following provisions:

POLICIES

LIFESTYLE BROKER, LLC requires that clients adhere to ALL policies posted on its website and throughout its wellness center(s). They include but are not limited to access to and use of the facilities, opening hours and conduct, availability of services, packages and memberships, pricing, payments, cancellations, refunds and other aspects of relationship between LIFESTYLE BROKER, LLC and its clients.

LIFESTYLE BROKER, LLC reserves the right to revoke, edit, augment, or replace the policies applicable to its wellness center(s) as it sees fit.

The version published on the website   TBD     shall always be considered the latest and prevail. It is recommended that clients review the latest information periodically to stay informed.  You may also request any updates by email, mail, or phone/text (770)746-3646

 

AGE LIMIT

To use any of LIFESTYLE BROKER, LLC wellness services, client must be at least 18 years of age. All clients younger than 18 are required to come to the first scheduled appointment together with a parent or legal guardian who must sign the Interest Form in person on the minor’s behalf.

Other Qualification Criteria

The wellness services provided by LIFESTYLE BROKER, LLC, although they may have certain health benefits, have been designed to enhance fitness, appearance and vitality in generally healthy individuals. For this reason, submission of a health-related questionnaire provided by LIFESTYLE BROKER, LLC is mandatory as part of the new client intake process.

It is client’s responsibility to truthfully and fully answer all questions asked by the staff of LIFESTYLE BROKER, LLC and to proactively disclose any medical conditions, temporary health problems, undergoing medical treatments, use of prescription medications, trying to conceive, being pregnant or breastfeeding, as they may impose risks of complications, as well as reduce effectiveness of the wellness services.

LIFESTYLE BROKER, LLC reserves the right to reject new service requests for any medical, safety or general concerns and to refuse, without a refund, to provide treatments to clients who have not obtained the requested medical clearance or show up for appointments unwell.

No services shall be provided to persons under influence of drugs or alcohol. 

 

AVAILABILITY OF SERVICES

LIFESTYLE BROKER, LLC reserves the right to change the list of offered services, as well as service packages and membership plans as it sees necessary.

All treatments are subject to availability. LIFESTYLE BROKER, LLC does not guarantee that all services will always be available or be uninterrupted. Treatments may be suspended, discontinued or replaced, and LIFESTYLE BROKER, LLC shall not be liable if a service becomes unavailable for any reason, at any time or for any period.

LIFESTYLE BROKER, LLC respects clients’ preferences but cannot guarantee client’s access to the same therapist or trainer, visit by visit.

LIFESTYLE BROKER, LLC reserves the right to close any of its facilities for maintenance, repair, expansion, special events or because of external factors, such us ordinances by authorities, emergencies or weather conditions, without an advance notice.

 
PACKAGES AND MEMBERSHIPS

All packages and memberships are a subject to approval by LIFESTYLE BROKER, LLC management.

A package or a membership starts on the date of its purchase, unless otherwise specified (the activation date, if different, should be requested by the client at the time of the purchase). Except for ongoing monthly subscriptions, all fees are payable upfront and are inclusive of the applicable taxes.

All packages and memberships are personal to the client and are non-assignable, non-transferable and non-refundable.

All packages and fixed-term memberships will expire automatically on the date of expiration set up at the date of its purchase. They are subject to the pre-defined number of sessions that can be attended during the validity period. Clients are required to observe the expiration dates of the purchased packages. Any unused sessions are not transferable or refundable and cannot be carried forward.

In case of travel or unforeseen circumstances, clients can apply to temporarily freeze their package or membership, but only if it has a term of 3 months or longer. The total acceptable freeze time is 1 week for 3-month packages, 2 weeks for 6-month packages and 4 weeks for 12-month packages. The minimum freeze period is 1 week. Any freeze request needs to be submitted in person or by e-mail at least 1 week ahead of the freeze date and will be a subject to approval by LIFESTYLE BROKER, LLC management. No package or membership can be frozen in retrospect or for a period that is shorter than a week.

 
PAYMENT METHODS AND TERMS

All LIFESTYLE BROKER, LLC services must be pre-paid.

The entire amount for a package will be charged upfront, on the day of purchase.

ANY membership will be charged upfront, on the day of purchase.

For memberships, the fee for the first 1 month plus 1-month security fee will be charged at once at the time of initiation. Succeeding months of the term will be charged as recurring payment through LIFESTYLE BROKER, LLC online payment gateway. Client shall be responsible for keeping the payment card information (Payment Method) up to date for recurring billing. If the payment is not successfully settled due to expiration, insufficient funds or otherwise, client nonetheless will remain responsible for any uncollected amounts and authorize LIFESTYLE BROKER, LLC to continue billing the Payment Method or any other payment method provided, as it may be updated. Failure to resolve a payment issue shall result in suspension of all services and may result in membership termination.

APPOINTMENTS

For availability, appointments are required for all wellness services offered by LIFESTYLE BROKER, LLC They can be made at the reception desk in person, by calling the center, or through the booking system online.

All bookings except for the initial consultation must be pre-paid.

Booking cancellations must be made at least 24 hours in advance. Failure to notify LIFESTYLE BROKER, LLC, late notification or showing up past the time of the booking will result in full payment for the session as a cancellation fee or deduction of one session if part of a package.

Gift Cards & Coupons

Gift cards & coupons must be presented in the center in order to redeem them for services.

Gift cards & coupons must be presented prior to service to verify validity.

LIFESTYLE BROKER, LLC is not responsible for sourcing the gift card number in their sales records should the client fail to present it.

Gift Cards are strictly non-refundable, valid for 12 months from the purchase date, and cannot be redeemed for cash.

LIFESTYLE BROKER, LLC reserves the right to refuse, cancel, or hold gift cards  or coupons for suspected fraud or other violations of policies.

 
CHANGES IN PRICING

LIFESTYLE BROKER, LLC reserves the right to retroactively adjust pricing of its services at any time.

Unless expressly communicated otherwise, any price changes to ongoing memberships will take effect on the next billing cycle upon advance notice communicated through means LIFESTYLE BROKER, LLC may deem appropriate, such as email, text, WhatsApp, or other. Unless client cancels the membership upon receipt of such notice, the price change will be deemed accepted.

Privacy, Personal Data, and its Security

Clients are fully responsible for maintaining the confidentiality of their accounts, user identification and passwords, and for restricting access to their electronic devices.

LIFESTYLE BROKER, LLC does not collect any personal information about individuals except when it is knowingly provided via the client registration form in the account creation process. LIFESTYLE BROKER, LLC may use this information to contact clients with important information.

LIFESTYLE BROKER, LLC makes every effort to ensure that all online transactions made are secure.

Client’s use of the website and other means of electronic communication with LIFESTYLE BROKER, LLC signifies acceptance of the terms and conditions stipulated in this document, including any revised changes.

 
OTHER CONDITIONS

The wellness center environment is not suitable and may not be safe for young children. For this reason, the minimum allowable age is 10, and the child must remain under continuous adult supervision while visiting.

Pets or any other animals are not permitted on LIFESTYLE BROKER, LLC premises.

LIFESTYLE BROKER, LLC is neither responsible nor liable for loss or theft of clients’ valuables.

No items belonging to LIFESTYLE BROKER, LLC can be removed from the premises.

LIFESTYLE BROKER, LLC reserves the right to refuse services, terminate packages without a refund, and to ask clients leave the premises if they damage the property, violate rules, disrespect or harass other clients or staff members or refuse to follow service-related instructions.

Clients agree that no claims will be made against LIFESTYLE BROKER, LLC, its owners, management, employees or subsidiaries for any reason and agree to release, indemnify, defend and hold them harmless from and against any claims, losses, damages, expenses, costs, or liabilities which may arise out of or in any way related to presence in LIFESTYLE BROKER, LLC locations or receiving LIFESTYLE BROKER, LLC services.

I hereby confirm that all information provided by me herein is correct to the best of my knowledge, and I have disclosed all health-related risk factors that I know of. I understand that treatment safety may depend on my health status.

By signing this document, I confirm that I have read, understood and agreed with the treatment-related risks, liability waiver, and provisions of the Lifestyle Broker, LLC Service Terms and Conditions.

By signing this document, I ALSO confirm that I have BEEN EXPLAINED and agree with the choice of consent level related to the use of the “before” and “after” photographs.

I am aware that, to withdraw my earlier given consent that I could do any time without any impact on the services I will be receiving, I must request it in writing.