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cryo sanctuary
Master WaiverCryo · EMS · BioCharger · Cancellation policy

One form for all of our services. Fill in your details once, answer the health questions, and sign at the end.

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 the best of your ability.

All provided information is confidential and protected. We will never share your information with any third parties unless required by law.

1

Your information

2

Your goals

What would you like us to help you achieve? Select all that apply. *

3

Health questionnaire

Please answer Yes or No to every question.

General

Are you pregnant or breastfeeding?

Are you currently on your menstrual period?

Heart, blood and circulation

Do you have heart problems or cardiovascular disease?

Do you have hypertension (high blood pressure)?

Do you have cerebrovascular disease, or have you had a stroke?

Do you have impaired arterial blood flow?

Do you have chronic venous insufficiency?

Do you have vasculitis (inflamed blood vessel walls)?

Do you have diabetes-related microvascular issues?

Do you have a bleeding or clotting disorder, a haemorrhagic disease, or recent trauma or bleeding?

Do you have an impaired lymphatic system?

Organs, cancer and other conditions

Do you have kidney or liver disease, damage or reduced function (including renal failure)?

Do you have thyroid disease?

Do you have cancer of any type, a malignant tumour, or undiagnosed lumps?

Are you undergoing chemotherapy or immune therapy?

Do you have epilepsy, including photosensitive epilepsy or any condition triggered by flashing light?

Cold sensitivity and sensation

Do you have a cold-induced condition, such as cold hemolysis, cryoglobulinemia, cold agglutination or cold allergies?

Are you hyper- or hyposensitive to cold?

Do you have a trophic disorder?

Do you have a sensory processing disorder?

Do you suffer from polyneuropathy?

Do you have areas of skin that lack normal sensation?

Do you have a disturbance of temperature or pain perception?

Implants and medical devices

Do you have a pacemaker, implanted defibrillator or other active implanted device?If yes, you must stay at least 6 feet away from the BioCharger.

Do you have an insulin pump, another drug pump, or a stent?An insulin pump must stay at least 6 feet away from the BioCharger.

Do you have a CGM or any other implanted or wearable electronic medical device?

Do you have implants or other parts with metal inside your body?

Do you have metal plating in or near the head or brain?

Do you have a metal contraceptive implant (copper IUD)?

Do you have a metal-based chemotherapy port?If yes, do not use the BioCharger within 6 feet.

Skin, muscles and recent treatments

Do you have open wounds or lesions, recent surgery, or scars?

Do you have acute inflammation or a skin condition?

Is your skin sunburned or frostbitten?

Do you have injured or otherwise impaired muscles?

Have you had Botox or fillers in the last 2 weeks?

Have you had any recent skin-sensitizing treatments, such as a chemical peel?

Please note that this list is indicative but not exhaustive. If you have any injury, illness, serious medical condition, or any health-related concern, we strongly recommend consulting a physician prior to using any of these services.

4

Localized High Impact Cryotherapy

Cryo Slimming, cryo facials and cryo for pain management

Localized cryotherapy is safe for most individuals; however, certain contraindications exist and potential side effects are possible. Reviewing the information below will help minimize the risk of unwanted reactions.

How it works, advisements and contraindications

What is Localized High Impact Cryotherapy?

For localized cryotherapy services, we use one of the newest and most effective technologies available on the market — the SubZero device by American Cryo.

The procedure involves spraying the treatment area with dry carbon dioxide (CO₂) vapor at temperatures as low as −108°F, delivered under pressure of up to 50 bar in short 90-second increments. The combination of precise targeting, extremely low temperatures, and powerful flow allows for faster and deeper cooling of affected tissues, producing quicker and more effective results.

This technique is not considered a medical treatment. However, rapid cooling of the skin and underlying tissue may be used for pain management, stimulation of cell regeneration, skin tightening and brightening, anti-aging facial treatments, and reduction of stubborn fat deposits and cellulite.

Thermal shock improves blood circulation in the treated area and helps reduce inflammation. When applied to fat cells — which are more sensitive to cold than other cells in the body — the cooling process triggers cryolipolysis, leading to apoptosis, or controlled and permanent destruction of subcutaneous fat tissue.

Advisements and Contraindications

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

Cold applications may feel slightly uncomfortable and can leave the skin pink for a short period while the skin temperature returns to normal. There is no damage and no recovery time required. If you experience burning sensations, pain, or significant discomfort at any time during treatment, we strongly advise you to immediately terminate the session at your own discretion.

Localized High Impact Cryotherapy for Pain Management

We use a high-pressure flow of gasiform CO₂ to lower tissue temperature in the treated area. This process, called cryostimulation, causes blood vessels to constrict in response to cold, followed by dilation and improved blood flow after treatment. This reduces inflammation and swelling and stimulates the release of hormones such as noradrenaline and beta-endorphins, which are powerful natural pain relievers.

Applications include athletic recovery, recovery from soft tissue, muscle, tendon, or overuse injuries, post-surgical recovery, 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 by individuals with cold allergies or cold-induced conditions.

Localized High Impact Cryotherapy for Fat Freezing / Body Sculpting

This process uses a phenomenon called cryolipolysis. Cooling targeted areas to the point where subcutaneous fat cells—highly sensitive to low temperatures—become damaged and die results in gradual slimming. After treatment, the body’s lymphatic system permanently eliminates the damaged fat cells.

Due to the strain placed on the body during elimination of cellular debris, fat freezing treatments should not be performed if you are pregnant, undergoing dialysis, have only one kidney, have any kidney or liver disease, or have an impaired circulatory system. Contraindications also include cold sensitivity or allergy, active cancer, or undergoing chemotherapy.

High Impact Cryo Facials

Cold applied to the face, neck, or décolletage causes blood vessels to constrict and then dilate, improving circulation and making the skin appear firmer and more toned. This process also reduces inflammation, helps fight bacterial conditions such as acne, and stimulates collagen production for anti-aging benefits.

Cryo facials should not be used if you are cold-intolerant or if your skin is highly sensitized due to sun exposure or treatments such as chemical peels. A two-week break is recommended following procedures such as Botox or dermal fillers.

Liability Waiver

By using localized cryotherapy services offered by Cryo Sanctuary and completing and signing this Intake Form before or during your first visit, you acknowledge the following:

  • You confirm that you have truthfully disclosed your current health condition and any past health-related events, including those listed as contraindications.
  • You understand that Cryo Sanctuary services are designed to enhance health, appearance, and vitality in generally healthy individuals and that all services have contraindications. You acknowledge that treatments should only be used if you do not have related risks or have obtained written medical consent.
  • You recognize the importance of informing Cryo Sanctuary staff of any changes in your health condition, including pregnancy.
  • You understand the need to postpone appointments if you feel unwell or experience symptoms such as fever, congestion, cough, shortness of breath, chest pain, dizziness, nausea, rash, or acute infection. Cancellation and package expiration policies still apply.
  • You acknowledge that results—especially for fat loss, cellulite reduction, or anti-aging—are not always immediate and may continue developing over weeks or months. Results vary based on individual body and lifestyle factors, and a minimum of five sessions with proper maintenance is essential for success.
  • You agree to follow all safety instructions provided by Cryo Sanctuary staff and to immediately report any discomfort or adverse effects during treatment.
  • You confirm that the procedure, including potential side effects and rare complications, has been explained to you. Minor frostbite may occur in rare cases and could lead to long-term sensitivity to temperature changes.
  • Based on the above, you voluntarily assume full responsibility for participating in these services and agree to indemnify and hold Cryo Sanctuary harmless from any consequences or related costs.
  • You acknowledge that no guarantee or warranty of results has been provided and that outcomes depend on multiple factors, including lifestyle and diet.
5

EMS Body Sculpting

Electromagnetic Muscle Stimulation

What EMS is, how it works and what to expect

What is Electromagnetic Muscle Stimulation (EMS)?

Electromagnetic Muscle Stimulation is a non-surgical body contouring treatment that uses high-intensity electromagnetic energy to stimulate large muscle groups in the body. These pulses are known as High-Intensity Pulsed Electromagnetic (HIPEM) technology. The energy induces continuous expansion and contraction of the muscles, delivering approximately 20,000 muscle contractions in just 30 minutes. This unique treatment helps build muscle while also assisting in fat reduction at the same time. It is most effective for clients close to their desired body shape looking for extra definition and toning in areas such as the upper arms, calves, thighs, buttocks, and abdomen. EMS helps improve muscle tone, increase strength, and enhance definition. Fat burning is a secondary effect, and EMS is not a weight-loss solution.

How does Electromagnetic Muscle Stimulation work?

Electromagnetic Muscle Stimulation uses safe, high-intensity electromagnetic pulses to activate muscles and create powerful contractions, similar to an intense workout. The electromagnetic energy is delivered through applicators placed on the skin over the targeted area. These pulses are delivered at such a fast rate that muscles work at a much higher capacity than during standard exercise. The treatment does not require anesthesia or numbing agents.

What can you expect during and after treatment?

The procedure is painless, although you may feel strong muscle contractions and a warming sensation during treatment. After the session, mild muscle soreness similar to an intense workout is common. Side effects are rare and may include temporary muscle fatigue, tingling or itching sensations, increased thirst, or tiredness for up to 24 hours. Mild redness may occur temporarily if radiofrequency is used. There is no downtime, and normal activities can be resumed immediately.

Is any special preparation or aftercare required?

No special preparation is required before treatment, but staying well hydrated is strongly recommended. On the day of the session, wear comfortable clothing and remove all metallic accessories and electronic devices. While no special diet is required, maintaining a healthy lifestyle will help support and prolong your results.

How many EMS treatments are needed?

For optimal results, 4–10 treatments spaced at least 2–3 days apart are recommended. Progress is reviewed throughout the treatment schedule. During your consultation, a personalised treatment plan will be created based on your goals, lifestyle, and body condition. Results vary from person to person, and some clients may require additional sessions.

How does lifestyle impact EMS results?

EMS treatments stimulate muscles and may have a secondary effect on stubborn subcutaneous fat, but they do not target visceral fat. Visceral fat can only be reduced through healthy lifestyle choices such as proper diet, exercise, hydration, quality sleep, and stress management. Poor lifestyle habits can lead to weight gain and may reduce the visibility of EMS results.

  • I am aware NOT TO wear any metallic accessories (such as jewelry, watch or clothes containing metallic threads or metallic accessories) during the treatment. I also acknowledge that I do not have any metallic or electronic implants (such as pacemakers, defibrillators, metallic IUDs, etc.)
  • The benefits and potential side effects associated with the Electromagnetic Muscle Stimulation and/or radio frequency procedure have been explained to me in detail. I have read the information above and give my consent to be treated with Electromagnetic Muscle Stimulation and/or radio frequency.
6

BioCharger

Waiver & safety acknowledgment

Safety first

Please let us know before your session if any of the following apply to you:

  • Pacemaker, implanted defibrillator, or insulin pump (must remain 6 feet away from the BioCharger)
  • CGM or other implanted or wearable electronic medical device
  • Photosensitive epilepsy or condition triggered by flashing light
  • Pregnant
  • Metal plating in or near the head or brain
  • Metal-based chemotherapy port (do not use within 6 feet)

Participants under 18 must have parent or legal guardian authorization and supervision.

Acknowledgment & release

I understand that the BioCharger is a general wellness service and is not a substitute for medical diagnosis or treatment.

I am participating voluntarily and understand that individual responses can vary. I agree to inform Cryo Sanctuary of any relevant health conditions or medical devices, and to stop the session and notify staff if I experience any discomfort.

I understand that participation may involve known or unknown risks. I voluntarily assume all risks associated with my participation and release Cryo Sanctuary, its owners, employees, contractors, and agents from any claims arising from my participation, including claims arising from ordinary negligence, to the fullest extent permitted by law.

7

Clinical photographs

Except for pain management purposes, clinical photographs are essential for tracking progress and staff education. They may also be used to support technological development by equipment suppliers.

Pictures may be obtained for clinical records. If pictures are used for education or marketing purposes, all identifying marks will be cropped or removed.

Different consent levels apply depending on how images are used. Please choose one consent option. At minimum, consent for case notes is required to monitor progress. Your choice of consent level will not affect your treatment.

8

48-hour cancellation policy and prepaid sessions

All prepaid or booked sessions are non-refundable.

  • Cancellation Notice: Clients must notify Cryo Sanctuary of any cancellations at least 48 hours before their scheduled appointment time. This allows us to offer the time slot to another client and ensures that our schedule remains flexible.
  • Late Cancellations: If a cancellation is made less than 48 hours before the appointment, a cancellation fee of 100% of the service cost will be charged. This fee will be automatically applied to the payment method on file.
  • No-Shows: If a client does not show up for their scheduled appointment without providing notice, the full service fee will be charged. No-shows significantly impact our ability to serve other clients and maintain a smooth operation.
  • Rescheduling: Clients who need to reschedule their appointment must do so at least 48 hours in advance to avoid any cancellation fees. Rescheduling within the 48-hour window will be subject to the same fees as a late cancellation.
  • Emergency Cancellations: We understand that emergencies happen. In cases of sudden illness, family emergencies, or other unexpected situations, please contact us as soon as possible. We may waive the cancellation fee at our discretion under these circumstances.
  • Policy Agreement: By booking an appointment with Cryo Sanctuary, you agree to this cancellation policy. We appreciate your understanding and cooperation.
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Optional communications

10

Authorization, waiver and consent

I, the client or the parent/legal guardian of a client under the age of 18, hereby confirm that all information provided by me in this form is accurate to the best of my knowledge. I confirm that I have disclosed all known health-related risk factors and understand that the safety of the treatment may depend on my health condition.

By signing this document, I confirm that I have read, understood, and agreed to the treatment-related risks, liability waiver, and the provisions outlined in the Cryo Sanctuary Service Terms and Conditions.

By signing this document, I also confirm that I have been fully informed about and agree with the selected consent level regarding the use of “before” and “after” clinical photographs.

I understand that I may withdraw my previously given consent at any time without affecting the services I receive. To do so, I acknowledge that a written request is required.

Signature *
Sign with your finger or mouse. If the client is under 18, the parent or legal guardian signs.

Your information is secure and will never be shared.