Intake Form | Advantage Care Cryotherapy

CLIENT INTAKE AND MEDICAL HISTORY

Full Name:*

Phone Number:*

Your email:*

Address:*

Emergency Contact Name:

Emergency Contact Phone Number:*

Do you have any of the following conditions? (Check all that apply):

Heart Condition

High Blood Pressure

Diabetes

Cold Sensitivity (I.e., Raynaud's disease)

Circulatory Issues

Pregnancy

Recent Surgery or Injury

Neurological Disorders

Metal Implants

Pacemaker or Electronic Implants

Other

If yes to "Other", please list:

Are you currenly under a physician's care?*

Yes

No

Are you currently taking any medications?*

Yes

No

If yes, please list:

Have you received medical clearance to participate in wellness services?*

Yes

No

What are your primary goals for visiting today? (Check all that apply)

Fat Reduction/Body Sculpting

Muscle Toning

Pain Relief/Recovery

Skin Rejuvenation

Detoxification

Athletic Performance

Stress Relief

Flexibility/Mobility

Other

If yes to "Other", please list:

LIABILITY, CONSENT & CLIENT AGREEMENT

Medical Clearance: I affirm that I am in good health and have either received or will obtain medical clearance as needed to participate in services at Advantage Care Cryotherapy LLC.*

Understanding of Services & Potential Risks: I understand that treatments may involve exposure to cold, heat, fight, vibration, or electronic stimulation. I accept any possible risks such as soreness, bruising, redness, or discomfort. I also understand that Brazilian Lymphatic Drainage and Wood Therapy may cause temporary swelling or detox symptoms.*

Individual Results May Vary: I understand that results vary depending on my individual health, consistency, and lifestyle. Advantage Care Cryotherapy LLC makes no guarantees of specific outcomes.*

Client Responsibility: I take full responsibility for disclosing accurate health information, following post-treatment care guidelines, and communicating any discomfort during treatments.*

Release of Liability: Thereby release Advantage Care Cryotherapy LLC, its owners, staff, and affiliates from any and all lability for injury, adverse reactions, or damages resulting iron services received.*

No Refund Policy / All Sales Are Finat: I understand and accept that all services, packages and product purchases are non-refundable and non-transferable. ALL SALES ARE FINAL.*

PHOTO & MEDIA CONSENT

Photo/Video Consent for internal Use: I give permission for Advantage Care Cryotherapy LLC to take photographs and/or videos for the purpose of documenting my treatment progress. These images will be kept confidential and used only for my client file. *

Photo/Video Consent for Marketing & Social Media: I give permission for Advantage Care Cryotherapy LLC to use photos or videos taken before, during, or offer my treatment for marketing, promotional, or educational purposes, including (but not limited to) social media, website, digital ads, and printed materials.*

I understand that my name or personal information will not be disclosed without my written consent.

I decline any use of my images for promotional purposes.

I confirm that the information provided is true and complete to the best of my knowledge. I have read. understood, and agree to the services, risks, liability waiver, refund policy, and photo consent terms.*

“I hereby declare that all the information I have provided in this form is true, complete, and accurate to the best of my knowledge and belief. I understand that any false, misleading, or incomplete information may affect the quality of care provided and could lead to consequences as outlined in the clinic's policies. I take full responsibility for the accuracy of the details submitted and agree to inform the clinic of any changes or updates as necessary.”*

I agree

By typing in my name and hitting summit I agee to the terms and conditions above.*

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