WAIVER | SF Cryo Toronto

Vital Cryotherapy Inc.

Whole Body Cryo
Waiver and Consent Form

Name

Date

Address

Mobile Phone

E-mail

Date of Birth

Sex

Referral from

List any medication (please do not include vitamins)

Do you have allergies of any kind?

Are you under medical care for any reason? If yes please be specific

Are you waiting for the results of any medical testing? If yes, please explain.

Other serious illnesses or medical conditions (please explain):

Initial

Safety Instructions for Whole Body Cryotherapy:

1) You must wear the cotton socks provided to avoid potential frostnip.
2)You must remove all metal objects (e.g. rings,piercings, necklaces, etc.) located below the neck.The presence of any implants (silicon, metal rods and plates) is not a problem for cryotherapy.
3) Treatments are limited to 3 minutes per session.
4) You must wear gloves provided to you during treatment if you feel your hands becoming too cold you may keep your hands visible at the upper rim of the cryochamber.
6) You may end the procedure at any time if you experience any problems or anxiety.
7) Abnormal skin sensitivity to the cold may be caused by certain foods, cosmetics, or medication,including, but not limited to tranquilizers, high blood pressure medication.
8) A person who is less than 18 years of age may not use whole body cryotherapy without parental consent.

Please Note: The cold therapy products and equipment have not been tested or approved by Health Canada or any other government agencies for the treatment and/or diagnosis of any illness or disease. Whole body cryotherapy is not a medical procedure. Use at your own risk.

Contraindications to using Whole Body Cryotherapy

Do not use this product if you are under the age of 14 years old. Do not use this product if you have any of the following medication conditions: pregnancy, severe hypertension (BP greater than 140/100), acute or recent myocardial infarction (heart attack; you must be cleared for exercise), unstable angina pectoris, arrhythmia, symptomatic cardiovascular disease, cardiac pacemaker, peripheral arterial occlusive disease, venous thrombosis, acute or recent cardiovascular incident (e.g. stroke; you must be cleared for exercise), uncontrolled seizures,severe Raynaud’s syndrome, malignant tumours, bleeding diathesis, severe untreated hypothyroidism, individual intolerance to cold, cold rash, tumor disease, symptomatic lung disorders, cancer, immunocompromised, bleeding disorders, severe anemia, infection, cold allergy, acrocyanosis, systemic vasculitis, cryoglobulinemia, agammaglobulinemia,cryofibrinogenemia, currently have or recently had a fever, active pulmonary tuberculosis.

Risks of Whole Body Cryotherapy

Fluctuations in blood pressure (due to peripheral vasoconstriction, blood pressure may briefly increase by up to 10 points systolic during treatment. This effect should reverse after the end of the procedure, as peripheral circulation returns to normal), allergic reaction to extreme cold (rare), claustrophobia, anxiety, activation of some viral conditions (cold sores) etc. due to stimulation of the immune system.

ACKNOWLEDGEMENT, RELEASE, WAIVER AND EXCLUSION OF LIABILITY AND INDEMNITY AGREEMENT

PLEASE READ THE FOLLOWING CAREFULLY, BY SIGNING BELOW YOU ARE WAIVING AND RELEASING LEGAL RIGHTS, AND AGREEING TO BE RESPONSIBLE FOR CERTAIN CLAIMS AGAINST VITAL CRYOTHERAPY INC., AND ITS REPRESENTATIVES. YOU ARE ADVISED TO OBTAIN LEGAL ADVICE PRIOR TO SIGNING THIS DOCUMENT.

IN CONSIDERATION OF VITAL CRYOTHERAPY INC. AGREEING TO PROVIDE AND ALLOWING YOU TO USE THE WHOLE BODY CRYOTHERAPY AND ACTIVITIES AND EQUIPMENT, YOU ACKNOWLEDGE AND AGREE AS FOLLOWS:

Definitions.In this Agreement, the following terms have the following meanings: (a) “Vital Cryotherapy” means, collectively, Vital Cryotherapy Inc., and all of its shareholders, directors, officers,employees, contractors, agents, trainers, representatives, therapists, volunteers, successors (including by amalgamation), assigns, subsidiaries, and affiliates.
(b) “Vital Cryotherapy Inc. Activities” means and includes all activities, treatment, therapies, sessions,operations. supervised and unsupervised uses of Equipment and Facilities, and all services that are provided, facilitated or undertaken by Vital Cryotherapy Inc. related to Whole Body Cryotherapy.
(c) “Claims” means any and all actions, causes of action, debts, dues, sums of money, damages, costs,claims, and demand, of every nature and kind in law, in equity, by rule of law or under any statute,including any and all claims relating to personal or physical injury or loss, death and/or property damage or loss, and any Claims based in negligence against Vital Cryotherapy Inc.(d) “Equipment” means any and all Whole Body Cryotherapy and equipment, machines, devices, and apparatuses whatsoever.
(e) “Facilities” means the facilities where the Equipment is located and/or used, and or where Vital Cryotherapy Inc. takes place or are provided.
(f) “Third Party” or “Third Parties” means any person, individual, corporation, company, partnership orother legal entity whatsoever and in whatever capacity, other than Vital Cryotherapy Inc. or you.
(g) “You” means the person who signs this Agreement.

Acknowledgments, Release, Waiver, Exclusions, Limitations and Indemnities. You acknowledgeand agree as follows:

I understand that Cryotherapy should not be construed as a substitute for medical examination, diagnosis,or treatment and that I should see a physician or other qualified medical specialist for mental or physical ailment that I am aware of.
(a)Risks.There are inherent risks involved in participating in the Equipment and any Vital Cryotherapy Inc. activities. These risks include, but are not limited to, physical injury, and/or property damage. You voluntarily assume all such risks.(b)Contraindications.Vital Cryotherapy Inc. has fully and satisfactorily explained to you the Contraindications of Whole Body Cryotherapy. You hereby confirm that you have accurately and completely disclosed to Vital Cryotherapy Inc. any and all of your medical and health conditions, past and current.
(c)Health Condition.You agree to inform Vital Cryotherapy Inc. of any unusual symptoms, health concerns or problems that may arise, whether as a result of, or in connection with use of the Equipment,Vital Cryotherapy Inc. Activities or otherwise. You have informed Vital Cryotherapy Inc. of any health condition or problem you may have that may react negatively to or be worsened or triggered by use of the Equipment. You may refuse to participate in any Vital Cryotherapy Inc. Activities or use of the Equipment. You may stop participating in any Vital Cryotherapy Inc. Activities or use of the Equipment at any time.
(d)Nature of Product.Vital Cryotherapy Inc. hasfully and satisfactorily explained to you the nature and purpose of Whole Body Cryotherapy. You understand that Whole Body Cryotherapy are not a substitute for medical examination, diagnosis or treatment. You understand that you should see a physician,chiropractor or other qualified medical practitioner for any medical condition that you may have.
(e)Equipment Use.You fully and satisfactorily understand the safe and proper use of the Equipment and facilities. You hereby agree to comply with and follow any and all rules and instructions of Vital Cryotherapy Inc. for the safe and proper use of the Equipment and Facilities.
(f)Release, Waiver and Indemnity.You hereby release and waive any and all Claims that you and any Third Parties, including your family members, may have against Vital Cryotherapy Inc. that are after the date you sign this document, in connection with, as a result of, that arise from, and/or with respect to;your attendance, involvement and/or participation in any Vital Cryotherapy Inc. or in any use of the Equipment. You hereby agree to be responsible for, and to indemnify and hold Vital Cryotherapy Inc. harmless, from any and all Claims (including for legal fees and expenses on a solicitor-client full indemnity basis incurred in endorsing this indemnity or defending such Claims) that may be made against Vital Cryotherapy Inc., whether by You or Third Parties, in connection with, as a result of, that arise from,and/or with respect to your attendance, involvement and/or participation in any Vital Cryotherapy Inc.Activities, or in any use of the Equipment.
(g)Exclusion of Liability.In no event shall Vital Cryotherapy Inc. be liable for any direct or indirect losses or damage whatsoever to You, including, but not limited to: any direct, indirect, special, incidental,general, consequential, punitive, exemplary or aggravated damages; any loss of profit, bargain, revenue,business, goodwill, investment, product or business interruption or work stoppage; losses or damages for or related to or in connection with injury or death of any person; or losses or damages for or related to or in connection with damage to or destruction of property; regardless of the causes of action, including anyform of negligence and even if Vital Cryotherapy Inc. had been advised or, or could have reasonably foreseen, the possibility, potential or likelihood of such damages or losses.
(h)Severability.Should a court of competent jurisdiction decide that any provision or part of this Agreement is void or invalid that part or provision shall be deemed to be severed from this Agreement and the remaining provisions or parts of this Agreement shall remain in full force and effect.
(i)Enurement.This Agreement shall enure to the benefit of and be binding upon your heirs, executors,administrators, successors and assigns.
(j)Jurisdiction.This Agreement shall be construed in accordance with the laws of the Province of Ontario.
(k)Understanding and Consent.You have read and understand this Agreement, and you have executed this Agreement freely and voluntarily, under no duress or threat of duress and without inducement,promise or guarantee from Vital Cryotherapy Inc. or others to you. You have signed this Agreement acknowledging this and you freely consent to your attendance, participation and involvement in Vital Cryotherapy Inc. Activities and use of the Equipment.
(l)Conditions.Because Cryotherapy is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep Vital Cryotherapy Inc. updated as to any changes in my medical profile and understand that there shall be no liability on Vital Cryotherapy Inc. part or its employees should I forget to do so. (m)Contraindications.Because Cryotherapy is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep Vital Cryotherapy Inc. updated asto any changes in my medical profile and understand that there shall be no liability on Vital Cryotherapy Inc. part or its employees should I forget to do so.
(n)Responsibly.Client hereby assumes full responsibilities for the receipt of the whole body cryotherapy treatment and releases and discharges Vital Cryotherapy Inc. and its employees from any and all claims,liabilities, damages, actions or causes of actions arising from the therapy received hereunder, including,without limitation, any damages arising from acts of active or passive negligence on the part of the employees, to the fullest extent of the law.
I release Vital Cryotherapy Inc. and its owners and employees from all legal liability during my participation in all treatment(s) received at Vital Cryotherapy Inc. from today forward.

Participant's Printed Name

Your Signature