Intake Form & Liability Waiver

Personal Information

First Name *

Last Name *

Email Address *

Contact Phone *

Date of Birth *

You must be 18 years or older. If under 18, a parent/guardian must complete this form.

Age Verification *

Yes, I am at least 18 years of age Under 18: Parent/Guardian completing this form

Parent/Guardian Full Name

Emergency Contact

Emergency Contact Name *

Emergency Contact Phone *

Relationship to Client

Medical Disclosure

Please select all conditions that currently apply to you. This information is critical for your safety during treatments.

Important Safety Notice

The following conditions may prevent you from safely receiving cryotherapy or related services. Please disclose all applicable conditions:

Other Medical Conditions or Concerns

I confirm that I have truthfully disclosed all known health conditions and will inform staff of any changes before receiving future treatments. *

Risks & Consent

I understand that cryotherapy, compression therapy, cupping therapy, and percussion therapy are wellness and recovery services and not medical treatments.

I acknowledge that potential side effects may include, but are not limited to:

Redness, numbness, or tingling
Temporary discomfort, bruising, or skin irritation
Dizziness or lightheadedness
Muscle soreness
Rare but possible frostbite or burns (for cryotherapy)

I understand the risks and consent to receive services from Recovery Plus. I confirm I am not under the influence of alcohol, drugs, or medication that could impair my ability to safely receive these services. I voluntarily assume all risks, known and unknown, associated with these services. *

Release & Indemnity

I hereby release Recovery Plus, its owners, employees, contractors, and affiliates from all liability for any injury, loss, or damages that may result from my participation in these services.

I agree to indemnify and hold harmless Recovery Plus from any claims, lawsuits, or expenses (including legal fees) related to my participation in these services, whether caused by negligence or otherwise.

I agree to indemnify and hold harmless Recovery Plus from any claims related to my participation. *

Prohibited Items During CO₂-Based Cryotherapy

Safety Requirements

For your safety, the following items are strictly prohibited during localized cryotherapy treatments:

Lotions, oils, or creams applied within the last 2 hours (risk of frostbite/skin injury)
Wet or damp clothing/towels in the treatment area
Metal jewelry, piercings, or body chains in or near the treated area
Watches, fitness trackers, or electronic devices
Adhesive bandages or medical patches on treatment area
Clothing with metal zippers, snaps, or decorations that may contact skin
Makeup in facial treatment areas (for localized facial cryo)

I understand and agree to remove or avoid these items before treatment. *

Photo/Video Consent (Optional)

Recovery Plus may take photos or videos during sessions for marketing, educational, or social media purposes. This is completely optional and will not affect your service.

Media Consent

I grant permission for photos/videos to be taken during my session for marketing or educational use I do not consent to any photo/video use

Acknowledgment & Signature

I understand this waiver and consent form will apply to all current and future sessions unless revoked in writing. *

Date Signed *

Full Name (Digital Signature) *

By typing your name, you agree that this constitutes your legal signature and confirms your agreement to all terms in this document.

Digital Signature Placeholder

Signature will appear here once form is completed

In the future, you may be asked to sign using a touchscreen or mouse for enhanced verification.