CORE Crotherpy & Wellness Physical Readiness Questionnaire

Core Cryotherapy Location

This questionnaire can be filled out using the form below and emailed to CORE Cryotherapy or you can download the PDF and print it and fill it out (it is about 6 pages long), everything is secure so nothing to worry about. The only thing that can't be signed here is Parental Consent Form.

Should you have any concerns or questions please call using the phone number at the top of the page.

NOTE: Please bring an ID with you

PLEASE READ CAREFULLY BEFORE SIGNING

This is a release of liability and a waiver of certain legal rights. Attached is a list of 'Contraindications' which preclude participation in all of our services. In addition, PLEASE BE AWARE, that if you experience any pain or mental/physical discomfort at any time during any of the services, you are advised to terminate the services immediately.

LIABILITY AND MEDICAL RELEASE AND INDEMNIFICATION AGREEMENT

In consideration of being permitted by CORE CRYOTHERAPY WELLNESS. to participate in any services, I hereby waive any and all claims and damages for personal injury or death which may occur as a result of my participation.

I understand and agree that:

1. In consideration for using the cryotherapy device (equipment) and other services, I hereby RELEASE, WAIVE, DISCHARGE, and HOLD CORE CRYOTHERAPY WELLNESS or any of its employees (hereinafter referred to as RELEASEE) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any damage or injury that may be sustained by me, while using the equipment or due to the use of the equipment and services.

2. I hereby confirm that no warranty, guarantee, or other assurance has been made to me covering the results of all services. I have been explained to and understand the administration of all services, including possible adverse reactions, side effects, or other complications. It is understood that this CONSENT is being given in advance of any administration of the services and is being given by me voluntarily to use the equipment.

3. I am fully aware of the risks connected with the use of the equipment and services. I am voluntarily participating in said services, equipment usage, and entering the above named premises to engage in such usage. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS that may be engaged in such an activity.

4. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEE from any costs that may incur due to the use of equipment by me.

5. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and shall be deemed as a RELEASE, WAIVER, AND DISCHARGE of the above named RELEASEE. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of Mississippi.

6. I understand that the equipment is designed for fitness and appearance enhancing use only by persons in good general health. I have been advised that if I suffer from any medical condition or illness whatsoever, I am NOT TO USE the services or the equipment without my doctor’s written permission.



Section Break


FAMILY MEDICAL HISTORY FORM
If you answer Yes a new selection will open to be answered.
Let us know who has the condition on the question asked.

My signature below constitutes my acknowledgment that
(1) I have read, understand, and fully agree to the foregoing CONSENT,
(2) I hereby give my authorization and consent and
(3) received the contraindication information. This CONSENT shall stand as long as I use the equipment and services at the location now and in the future.

Furthermore, I agree that I will comply with all instructions on the use of all the equipment and that I am using these services at my own risk. I agree to use all sessions within the terms of the contract dates and understand that refunds are not given on unused portions of purchased packages.

PARENTAL CONSENT FORM FOR MINORS UNDER THE AGE OF 18

Please complete this portion in the facility, just ask an attendant for the parental consent form.
Thanks,
Management

Our Ridgeland Location

141 Township Avenue
Suite 107
Ridgeland, MS 39157
Call Us » (601) 707-5676

Hours of Operation

Monday - Friday 9:30 - 6
Saturday 10 - 4
Sunday Closed
Closed All Holidays

Disclaimer:

The services provided have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. The material on this website is provided for informational purposes only and is not medical advice. Always consult your physician before beginning any treatment program.