Consolidated Waiver Services Form

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 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.

Introduction: 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.

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.

Part I: Tell Us About Your Goals and Health History

First name

Last name

Birthday

Phone

Emergency contact name

Emergency contact number

How did you hear about us?

Are you pregnant?

Yes No

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

Yes No

Are you hyper- or hyposensitive to cold?

Yes No

Do you have a trophic disorder?

Yes No

Do you have any sensory processing disorder?

Yes No

Do you suffer from polyneuropathy?

Yes No

Do you have a deficient kidney or liver function?

Yes No

Do you have an impaired lymphatic system?

Yes No

Do you have vasculitis (inflamed blood vessel walls)?

Yes No

Do you have diabetes-related microvascular issues?

Yes No

Do you have impaired arterial blood flow?

Yes No

Do you have chronic venous insufficiency?

Yes No

Do you have a blood disorder related to coagulation?

Yes No

Do you have cancer or undiagnosed lumps?

Yes No

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

Yes No

Have you had any recent skin-sensitizing treatments

Yes No

Do you have any open wounds or lesions?

Yes No

Is your skin sunburn or frostbitten?

Yes No

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 localized high impact cryotherapy.

Part II. 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.

Part III. 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.

Part IV. Consent to Use 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.

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.

Consent to Open Publication: I consent to anonymous publication of my progress images in journals, textbooks, marketing materials, or open-access websites. Anonymity means images will focus only on treated areas without showing my face or disclosing my identity.

Intials

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CONSENT TO CASE NOTES ONLY. I understand that the illustrations requested here, to which I have agreed, will only form part of my confidential treatment records and will be used by nobody but the Cryo Sanctuary staff directly involved in providing the services of my choice.

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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

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