Recovery Services Waiver & Informed Consent

Client Information

Full Name *

Date of Birth *

Phone Number *

Email Address *

Home Address *

City *

State *

ZIP Code *

Emergency Contact *

Relationship *

Emergency Contact Phone *

Acknowledgement of Services

Recover Cryo provides mobile wellness and recovery services designed to support recovery, mobility, flexibility, circulation, and overall physical wellness. Services may include, but are not limited to:

Localized Cryotherapy
Compression Therapy
Assisted Stretch Therapy
Other recovery services offered by Recover Cryo

I understand that these services are intended to promote recovery and general wellness and are not intended to diagnose, treat, cure, or prevent any disease, illness, or medical condition.

I understand that Recover Cryo does not provide medical care and that participation in any service is voluntary. I acknowledge that these services should not replace evaluation, diagnosis, treatment, or advice from a licensed physician or other qualified healthcare professional.

I understand that if I am experiencing severe pain, illness, an emergency medical condition, or symptoms requiring medical attention, I should seek immediate medical care and should not rely upon Recover Cryo services as a substitute.

I understand that no guarantees, warranties, or promises have been made regarding the effectiveness or outcome of any recovery service provided by Recover Cryo. Individual results vary depending upon each person's health status, medical history, activity level, compliance with recommendations, and numerous other factors beyond Recover Cryo's control.

Client Initials *

Medical Disclosure

My signature on this document certifies that I have truthfully and accurately disclosed my medical history to the best of my knowledge.

I understand that my health information is important for determining whether a recovery service is appropriate for me and for helping reduce unnecessary risk during treatment.

I certify that:

I have accurately disclosed all known medical conditions, illnesses, surgeries, injuries, medications, allergies, implanted medical devices, and any other health information that may affect my participation. I understand that withholding, omitting, or providing inaccurate medical information may increase my risk of injury or other complications. I agree to immediately notify Recover Cryo if my medical condition, medications, pregnancy status, injuries, or overall health changes before any future appointment. I understand that Recover Cryo reserves the right to postpone, modify, or refuse treatment if my medical history, current condition, or treatment environment may present an unreasonable safety risk. I understand that I am responsible for consulting my physician if I have questions regarding whether cryotherapy, compression therapy, or assisted stretch therapy is appropriate for my specific medical condition.

I understand that failure to disclose relevant medical information may affect my safety during treatment and may limit Recover Cryo's ability to provide services safely.

Client Initials *

Health Screening & Contraindications

Please indicate whether you currently have, or have previously been diagnosed with, any of the following conditions. This information is used solely to help determine whether recovery services may be appropriate for you.

Circulatory Conditions

Raynaud's Syndrome Poor circulation Blood clotting disorder Deep Vein Thrombosis (DVT) Severe vascular disease Peripheral artery disease Chronic swelling or edema

Other:

Cardiovascular Conditions

Pacemaker or implanted cardiac device Heart disease History of heart attack Uncontrolled high blood pressure Low blood pressure causing dizziness History of stroke

Other:

Neurological Conditions

Epilepsy or seizure disorder Neuropathy Loss of sensation Multiple sclerosis Other neurological condition

Other:

Medical Conditions

If you answered YES to any condition above, please provide additional details below.

I certify that the information provided above is complete and accurate to the best of my knowledge.

Client Initials *

Possible Risks and Complications

Although Recover Cryo strives to provide services in a safe, professional, and controlled manner, I understand that all wellness and recovery services involve some degree of inherent risk. I acknowledge that even when appropriate precautions are followed, adverse reactions or unexpected outcomes may occur.

I understand that possible temporary side effects may include, but are not limited to:

Redness of the skin
Tingling sensations
Temporary numbness
Mild swelling
Skin sensitivity
Temporary discomfort
Muscle soreness
Joint stiffness
Bruising
Fatigue following treatment
Temporary dizziness
Temporary light-headedness
Increased soreness during the body's natural recovery process

I understand that while uncommon, more serious complications may include:

Frostbite
Cold-related burns
Skin blistering
Changes in skin pigmentation
Nerve irritation
Aggravation of an existing injury
Allergic reaction
Fainting
Falls due to dizziness or instability
Circulatory complications in susceptible individuals
Other unforeseen medical complications

I understand that individual responses to recovery services vary significantly and that Recover Cryo cannot predict or guarantee how my body will respond to treatment.

I agree to immediately notify my practitioner if I experience:

Excessive pain
Burning sensations
Severe numbness
Difficulty breathing
Chest pain
Dizziness
Loss of balance
Unusual swelling
Skin discoloration
Any symptom that causes concern before, during, or after treatment

I understand that Recover Cryo may immediately discontinue treatment if continuing would be unsafe or if I fail to communicate symptoms that may increase my risk of injury.

Client Initials *

Assumption of Risk

I understand that participation in localized cryotherapy, compression therapy, assisted stretch therapy, and any other recovery services offered by Recover Cryo involves risks that cannot be completely eliminated, regardless of the level of care exercised by Recover Cryo or its practitioners.

I acknowledge that these risks may include, but are not limited to, temporary redness, numbness, tingling, bruising, swelling, skin sensitivity, muscle soreness, dizziness, discomfort, aggravation of a pre-existing condition, allergic reactions, cold-related injuries, nerve irritation, circulatory complications, falls, and other known or unforeseen risks associated with wellness and recovery services.

I understand that no guarantees or warranties have been made regarding the effectiveness or outcome of any treatment. I acknowledge that recovery timelines, pain reduction, mobility improvements, and other results vary between individuals and cannot be predicted or promised.

I voluntarily choose to participate in these services with full knowledge and understanding of the potential risks involved. I accept personal responsibility for my participation and acknowledge that I have had the opportunity to ask questions regarding the services offered, the associated risks, expected outcomes, and available alternatives.

I understand that I may refuse or discontinue treatment at any time and that Recover Cryo may also discontinue treatment whenever continuing would not be in my best interest or may create an unsafe situation.

By initialing below, I acknowledge that I fully understand the risks described above and voluntarily accept those risks as a condition of receiving services from Recover Cryo.

Client Initials *

Client Responsibilities

To promote a safe treatment environment, I agree that I will:

Provide complete and truthful medical information before each appointment. Inform Recover Cryo of any changes to my health, medications, injuries, surgeries, pregnancy status, or medical conditions before receiving future services. Follow all instructions provided before, during, and after treatment. Immediately notify my practitioner if I experience pain, dizziness, burning, excessive discomfort, numbness, or any unusual symptoms. Wear clothing appropriate for the treatment being provided. Remove jewelry, watches, or other accessories from the treatment area when requested. Maintain appropriate hydration before and after treatment when recommended. Avoid participating in treatment while under the influence of alcohol, illegal drugs, or any substance that may impair my ability to communicate or safely participate. Notify Recover Cryo immediately if I believe I am experiencing an adverse reaction following treatment.

I understand that failure to comply with these responsibilities may increase my risk of injury and may result in Recover Cryo refusing or discontinuing services.

Client Initials *

Medical Emergency Authorization

In the unlikely event that I become ill, injured, unconscious, or otherwise unable to communicate during treatment, I authorize Recover Cryo to contact emergency medical services (911) and seek emergency medical assistance on my behalf when deemed reasonably necessary.

I understand that Recover Cryo will make reasonable efforts to contact my listed emergency contact whenever practical.

I acknowledge that any medical expenses resulting from emergency treatment, ambulance transportation, hospitalization, or follow-up care remain my sole responsibility.

I agree that Recover Cryo shall not be held responsible for medical decisions made by emergency responders, physicians, hospitals, or other healthcare providers after emergency medical services have been contacted.

Client Initials *

Release of Liability

In consideration of receiving services from Recover Cryo, I, on behalf of myself, my spouse, heirs, executors, administrators, personal representatives, successors, assigns, and anyone acting on my behalf, voluntarily release, waive, discharge, and hold harmless Recover Cryo, its owner, employees, contractors, independent contractors, agents, representatives, volunteers, affiliates, and any associated persons from any and all claims, demands, actions, causes of action, liabilities, losses, damages, costs, expenses, attorney's fees, or judgments of any kind arising out of or related to my voluntary participation in any services provided by Recover Cryo.

This release applies to all services provided by Recover Cryo, including but not limited to localized cryotherapy, compression therapy, assisted stretch therapy, wellness consultations, demonstrations, promotional events, educational sessions, and any future recovery services offered by the business.

I understand that this Release of Liability applies to injuries, illnesses, property damage, financial loss, emotional distress, economic damages, or any other loss that may occur before, during, or after participation in Recover Cryo services, regardless of whether such claims are known or unknown at the time of signing.

I understand that nothing in this agreement is intended to release Recover Cryo from liability for gross negligence, reckless misconduct, intentional wrongdoing, or any liability that cannot legally be waived under applicable law.

I acknowledge that my participation is entirely voluntary and that I assume full responsibility for my decision to receive services.

Client Initials *

Indemnification

I agree to defend, indemnify, and hold harmless Recover Cryo, its owner, employees, contractors, representatives, agents, and affiliates from any claims, demands, lawsuits, liabilities, damages, costs, or expenses, including reasonable attorney's fees, arising from:

My failure to provide accurate or complete medical information. My failure to follow instructions provided before, during, or after treatment. My failure to disclose medications, injuries, allergies, surgeries, pregnancy, or other relevant medical conditions. My negligent or intentional actions while receiving services. Claims brought by third parties arising from my conduct or omissions.

I understand that this obligation survives the completion of my treatment.

Client Initials *

Mobile Service Acknowledgement

I understand that Recover Cryo operates as a mobile recovery service and provides treatment at client-selected locations, including private residences, fitness facilities, sporting venues, workplaces, hotels, businesses, and other mutually approved locations.

I acknowledge that I am responsible for ensuring the treatment location is reasonably safe, clean, accessible, and free from hazards that may interfere with treatment or create unnecessary risks.

I understand that Recover Cryo reserves the right to delay, modify, relocate, or refuse services whenever the treatment environment is determined to be unsafe, unsanitary, excessively confined, affected by severe weather, or otherwise unsuitable for professional recovery services.

I understand that treatment may also be postponed or discontinued if equipment cannot be safely operated or if environmental conditions may increase the risk of injury to either the client or practitioner.

I acknowledge that mobile services may occasionally require adjustments due to traffic conditions, weather, parking limitations, public events, equipment transportation, or other circumstances beyond Recover Cryo's reasonable control.

Client Initials *

From time to time, Recover Cryo may request permission to capture photographs, video recordings, testimonials, or other media for educational, promotional, marketing, social media, website, or business purposes.

I understand that my participation is entirely voluntary and that declining permission will not affect my ability to receive services.

Please indicate your preference below:

I authorize Recover Cryo to photograph, record, and use my likeness, voice, testimonials, and related media for marketing, educational, promotional, advertising, website, and social media purposes without additional compensation. I do not authorize Recover Cryo to photograph, record, or use my likeness, voice, testimonials, or any other identifiable media.

I understand that I may withdraw my consent for future media use by providing written notice to Recover Cryo; however, I acknowledge that materials already published or distributed before such notice may not be capable of being removed or recalled.

Client Initials *

Privacy & Confidentiality

Recover Cryo is committed to protecting the privacy and confidentiality of your personal and health information. Information collected before, during, and after treatment is used solely for providing services, maintaining business records, communicating with clients, complying with legal obligations, and improving the quality of care.

I understand that Recover Cryo will make reasonable efforts to safeguard my personal information and will not disclose my health or personal information to third parties except:

When required or permitted by applicable law. When necessary to protect my health or safety or the safety of others. With my written authorization.

I acknowledge that electronic communication, including email, text messaging, online scheduling platforms, and electronic document storage, may be used in connection with my services. While reasonable security measures are implemented, I understand that no electronic system can be guaranteed to be completely secure.

By signing this agreement, I consent to the collection, storage, and use of my personal information as described in this waiver.

Client Initials *

Cancellation & Appointment Policy

Recover Cryo strives to provide timely and reliable mobile recovery services. To ensure appointment availability for all clients, I acknowledge and agree to the following scheduling policies.

I understand that appointments should be cancelled or rescheduled as early as reasonably possible. I understand that repeated late cancellations or missed appointments may result in service restrictions or refusal of future appointments. I understand that Recover Cryo reserves the right to cancel or reschedule appointments due to weather, equipment issues, emergencies, unsafe conditions, or other circumstances beyond its reasonable control. I understand that arriving unprepared or failing to meet treatment requirements may require my appointment to be postponed.

I acknowledge that Recover Cryo will make reasonable efforts to accommodate scheduling changes whenever possible; however, appointment availability cannot be guaranteed.

Client Initials *

Client Acknowledgement of Understanding

By initialing below, I acknowledge and affirm that:

I have carefully read this entire Recovery Services Waiver and Informed Consent. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I fully understand the nature, benefits, limitations, risks, and possible complications associated with the services I choose to receive. I understand that no guarantees or warranties have been made regarding the outcome of any treatment. I certify that the information I have provided is true, complete, and accurate to the best of my knowledge. I understand that it is my responsibility to notify Recover Cryo of any changes to my health before future treatments. I voluntarily choose to receive services from Recover Cryo.

Client Initials *

By signing this document, I voluntarily consent to receive recovery and wellness services provided by Recover Cryo, including those selected by me now or in the future, as determined to be appropriate by Recover Cryo within the scope of its services.

I understand that I may decline or discontinue any service at any time before or during treatment by informing my practitioner.

I acknowledge that I have been informed of the nature of the services, the reasonably foreseeable risks and benefits, available alternatives, and the limitations of the services being provided.

I understand that Recover Cryo does not diagnose medical conditions, prescribe medications, or replace the advice, diagnosis, or treatment provided by licensed physicians or other qualified healthcare professionals.

I voluntarily choose to participate in these services and provide my informed consent freely, knowingly, and without coercion.

I voluntarily consent to receive services from Recover Cryo. I understand that I may withdraw my consent at any time before or during treatment.

Client Initials *

Client Eligibility for Treatment

I certify that, to the best of my knowledge, I am physically and medically eligible to receive the services I have requested from Recover Cryo.

I understand that Recover Cryo relies upon the accuracy and completeness of the medical information that I provide when determining whether services may be appropriate.

I acknowledge that Recover Cryo reserves the right to postpone, modify, or refuse treatment whenever there is reason to believe that providing services may not be in my best interest or could present an unreasonable health or safety risk.

I have truthfully disclosed all known medical conditions, injuries, medications, allergies, and other relevant health information. I understand that failing to disclose relevant medical information may increase my risk of injury or adverse reactions. I understand that Recover Cryo may decline or discontinue services if treatment is determined to be inappropriate or unsafe.

Client Initials *

Governing Law

This Recovery Services Waiver and Informed Consent shall be governed by and interpreted in accordance with the laws of the State of Georgia, without regard to its conflict of law principles.

I agree that any dispute, claim, or legal proceeding arising from or relating to this agreement or any services provided by Recover Cryo shall be brought exclusively in a court of competent jurisdiction located within the State of Georgia, unless otherwise required by applicable law.

I acknowledge that I have had the opportunity to seek independent legal advice regarding this agreement before signing it and that I voluntarily accept its terms.

Client Initials *

Severability

If any provision of this Recovery Services Waiver and Informed Consent is determined by a court of competent jurisdiction to be invalid, illegal, or unenforceable, that provision shall be modified or interpreted only to the extent necessary to make it enforceable, or, if modification is not possible, it shall be severed from this agreement.

Any such determination shall not affect the validity, enforceability, or legal effect of the remaining provisions, which shall continue in full force and effect to the maximum extent permitted by applicable law.

I acknowledge that it is the intention of both Recover Cryo and myself that this agreement remain enforceable even if one or more provisions are later found to be invalid or unenforceable.

Client Initials *

I consent to the use of electronic communications in connection with my services, including appointment confirmations, reminders, invoices, receipts, treatment documents, follow-up information, and other communications related to Recover Cryo.

I understand that these communications may be provided by email, text message (SMS), electronic forms, online scheduling platforms, or other electronic methods approved by Recover Cryo.

I acknowledge that electronic communications may not always be completely secure and that, while Recover Cryo will use reasonable safeguards to protect my information, no electronic transmission or storage system can be guaranteed to be completely secure.

I further agree that my electronic signature, digital signature, typed name, or electronic acknowledgment shall have the same legal force and effect as my handwritten signature and shall constitute my legally binding acceptance of this Recovery Services Waiver and Informed Consent.

I consent to receive communications electronically. I understand that my electronic signature carries the same legal effect as a handwritten signature.

Client Initials *

Confidentiality Notice

Recover Cryo respects the privacy of every client and is committed to maintaining the confidentiality of personal and health information collected in connection with the services provided.

Client information will be maintained in accordance with applicable federal and state laws and will be used only for purposes including, but not limited to:

Providing treatment and client care. Maintaining business and treatment records. Scheduling appointments and communicating with clients. Complying with legal, regulatory, insurance, or public health obligations.

Except where disclosure is required or permitted by law, Recover Cryo will not knowingly release your personal information to third parties without your authorization.

By signing this agreement, I acknowledge that I have read and understand this Confidentiality Notice.

Client Initials *

Client Signature

By signing below, I certify that I have carefully read this entire Recovery Services Waiver and Informed Consent, fully understand its contents, have had the opportunity to ask questions, and voluntarily agree to all terms and conditions contained within this document.

I acknowledge that this agreement is legally binding upon myself, my heirs, executors, administrators, personal representatives, successors, and assigns.

Client Full Legal Name *

Client Signature *

Draw your signature in the box above.

Date *

Enter the client's date of birth above to determine whether this section is required.

This section must be completed only if the client is under the age of eighteen (18) years or is otherwise legally unable to provide informed consent.

I certify that I am the parent or legal guardian of the client identified in this agreement and that I have the legal authority to consent to treatment on the client's behalf.

I acknowledge that I have read and understand this entire Recovery Services Waiver and Informed Consent and voluntarily authorize the minor or legally protected individual to receive services provided by Recover Cryo.

I agree to accept full responsibility for the decisions made on behalf of the client and agree to all terms, conditions, releases, acknowledgements, and obligations contained within this agreement.

Parent / Legal Guardian Full Name

Relationship to Client

Parent / Legal Guardian Signature

This signature is required only when the client is under 18.

Date

Practitioner Acknowledgement

For Recover Cryo practitioner use only. This section is not completed by the client.

I acknowledge that I have reviewed this Recovery Services Waiver and Informed Consent with the client (or the client's parent/legal guardian when applicable), answered any questions presented, and determined that the client appears to understand the information provided before receiving services.

Based upon the information disclosed by the client, I have determined that treatment is appropriate within the scope of services offered by Recover Cryo, subject to the limitations, precautions, and professional judgment exercised during treatment.

Practitioner Name

Practitioner Signature

Date

Document Acknowledgement

This Recovery Services Waiver and Informed Consent shall remain valid for all future services provided by Recover Cryo until the Client submits an updated medical history that materially changes their eligibility for treatment, Recover Cryo issues a revised waiver requiring a new signature, or applicable law requires execution of a new agreement. Recover Cryo may also request that this document be updated periodically to ensure the accuracy of the Client's health information and continued suitability for services.

Submit Recovery Waiver

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Recovery Services Waiver & Informed Consent

Client Information

Acknowledgement of Services

Medical Disclosure

Health Screening & Contraindications

Circulatory Conditions

Cardiovascular Conditions

Neurological Conditions

Medical Conditions

Possible Risks and Complications

Assumption of Risk

Client Responsibilities

Medical Emergency Authorization

Release of Liability

Indemnification

Mobile Service Acknowledgement

Photography, Video & Media Consent

Privacy & Confidentiality

Cancellation & Appointment Policy

Client Acknowledgement of Understanding

Consent to Receive Services

Client Eligibility for Treatment

Governing Law

Severability

Electronic Communications & Electronic Signature Consent

Confidentiality Notice

Client Signature

Parent or Legal Guardian Consent

Practitioner Acknowledgement

Document Acknowledgement

Submit Recovery Waiver