Cryotherapy Questionnaire and Waiver

The first sheet covers patient information, any medications and allergies, and several lists of ailments, and conditions. Conditions include: Venereal Disease, Seizures, Rheumatic Fever, Shortness of Breath, Asthma, Heart Murmur, Glaucoma , Heart Valve Disease, High Blood Pressure, Cancer, and Low Blood Pressure. The second sheet includes check boxes for statements like: "I am fully aware of the risks and hazards connected with the use of the Equipment, including the risk of physical injury or disability as the result of such injury, and I am voluntarily participating in said Equipment usage, and entering the above named premises to engage in such usage. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury that may be sustained, or any loss or damage to property as a result of being engaged in such an activity. I further hereby agree to indemnify and hold harmless the releasees from any loss, liability, damage or costs that may incur due to the use of Equipment by me." Signature boxes are also available.