Full Name

Date of Birth

Address

Contact Number

Your Email

Emergency Contact Name

Relationship

Emergency Contact Number

Are you currently on any medication?

YesNo

If yes, please state:

Absolute contraindications to Cryostimulation: Tick any that apply:

Cold intolerance (Cryoglobulinemia, Cryofibrinogenemia, Cold Urticaria)Thromboembolic changes or inflammation in the venous systemAgammaglobulinemiaHyperthyroidismCancerAcute respiratory or lung diseasesSevere anemiaPregnancy (after 4th month)Use of antipsychotics or alcohol

Contraindications for local cryostimulation: Tick any that apply:

Open wounds or ulcersGangrenous lesionsHypothyroidismCold intolerance

Confirmation:

I confirm that to the best of my knowledge, the answers I have given are correct and I have not withheld any information that may be relevant to my treatment. I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform my therapist of my current medical or health conditions and to update this history as a current medical history is essential for her / him to execute appropriate treatment procedures. Due to Cryostimulation being contraindicated under certain conditions. I confirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part

Disclaimer:

I fully understand the administration of the process, including possible adverse reactions, side effects or the other possible complications. It is understood that this Agreement is being given in advance of any treatment. I understand that Cryostimulation is provided for the purpose of relaxation, stress reduction, relief and recovery of muscular tension, recovery from surgery, help several skin conditions and aid in cellulite reduction and detoxification. I further understand that Cryostimulation should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a GP, Chiropractor or another qualified medical specialist for any mental or physical ailment that I am aware of

Consent:

By sending the consent form I agree that I have read and understood the contraindications to Cryostimulation treatments. The risks of the treatment have been explained to me and I have had an opportunity to discuss and clarify any concerns with the specialist or trained personnel. The signature below confirms my consent to undergo Cryostimulation treatment/s

Full Name

Date of Birth

Address

Tel / Mobile

Email

How did you find me?

Please give details of any health concerns:

Are you allergic/sensitive to any of the following:
Sweet almond oil, grape seed oil, olive oil, shea butter, beeswax, essential oils, or anything else that may be used in your massage?

Disclaimer:

I understand that the practitioner is not a medical professional and does not diagnose or treat medical conditions. It is my responsibility to disclose any conditions for which I am receiving treatment.

Consent:

I confirm that the information I have provided is complete and accurate to the best of my knowledge, and I consent to receiving massage therapy.

I accept and consent to treatment as described above.