Medical Waivers

Please review our medical waivers listed below. Prior to receiving any of our services, you will be required to complete the waiver associated with the service you will be using.

Floating

We at Total Rejuvenation provide floatation therapy which stimulates blood flow throughout the body’s tissues, provides a deep state of relaxation which allows our brains to enter into the theta brain wave and releases natural endorphins. To ensure a comfortable, clean and safe floatation experience, I the undersigned, do hereby agree to and consent to the following:

By checking each line, you agree to the following:
__ I do not have any communicable or infectious disease, illness, open sore or skin disorder(required)
__ I do not have a condition, nor am I medicated in any manner, which may be adversely affected by profound relaxation and/or immersion in concentrated magnesium sulfate (Epsom salt) water solution (required)
__ I am not under the influence of any non-prescription medication, drug or alcohol (required)   I do not have a history of high (>180/120) or low (<90/50) blood pressure (required)
__ I do not have kidney disease or chronic heart disease (required)
__ I do not suffer from uncontrolled seizures or epilepsy (required)
__ I will not use the float tank with oils or creams in my hair or on my body (required)
__ I have not applied hair dye, hair product with pigment in it or skin tanning products in the past 10 days (required)
__ I will shower before and after my float, as instructed by a staff member (required)
__ I am not currently menstruating, and if I am, I agree to use an insertable type feminine hygiene product (tampon, cup etc) (required)
__ If I am pregnant, I have consulted with my healthcare provider prior to using the float tank(required)
__ I understand that if I contaminate the float tank, I may be charged for the replacement of the water, salt and filter up to $1,200 (required)

The following are used in the Floatation Pods and Suites:

  • Pharmaceutical grade Epsom salt (Magnesium Sulfate mgSO4)
  • Natural Enzymes and non-toxic, biodegradable cleaning products
  • 35% food grade hydrogen peroxide as a disinfectant
  • Ultraviolet and Ozone sanitation system

__ I understand the above items are used in the Floatation Pods and Suites (required)

__ I agree to take full responsibility for my thoughts and actions while in the Float Suite and understand that each individual may have a unique experience. I have or will receive(d) an orientation which familiarizes me with the safe and appropriate use of the Float Suite. I hereby confirm that I fully understand all statements above completely and take on all risks associated with Floatation Therapy. (required)

Cryo

In order to provide you with a safe experience, please fill this form out to the best of your ability. We will review your answers during the visit. All information is confidential.

By checking each line, you agree to the following:
__ Medical History: (Please answer ALL of the following questions)
__ Major Cardiovascular/Pulmonary Risk Factors:
__ I have never had a Heart Attack or Cerebrovascular Accident. (required)
__ I do not have Unstable Angina Pectoris. (required)
__ I do not have Arrhythmias. (required)
__ I do not have any Peripheral Arterial Occlusive Disease. (required)
__ I do not have High Blood Pressure (BP>180/100 mmHg). (required)
__ I do not have a Pacemaker. (required)
__ I have not had a Heart Bypass or Valvular Disease. (required)
__ I do not have Congestive Heart Failure. (required)
__ I do not have Chronic Obstructive Pulmonary Disease (COPD). (required)

Circulatory Risk Factors:
__ I do not have any major circulatory dysfunction. (required)
__ I do not have cold allergies or have hypersensitivity to cold. (required)
__ I do not have Raynaud’s Syndrome. (required)
__ I do not have any blood disorders (ie. Anemia or Sickle Cell Disease). (required)
__ I do not have Intrathecal Pump Implant (pain pump). (required)
__ I do not have Deep Vein Thrombosis (DVT). (required)

Other Risk Factors:   
__ I do not have any open wounds, sores. or healing disorders. (required)
__ I am not Pregnant. (required)
__ I do not have a history of Seizure Disorders. (required)
__ I am not under the influence of drugs or alcohol. (required)
__ I am not currently being treated for any infection. (required)

Contraindications to using Whole Body Cryotherapy:

  • Pregnancy
  • Severe Hypertension (BP>180/100)
  • Acute or recent Myocardial Infarction
  • Unstable Angina Pectoris
  • Arrhythmia
  • Complex Regional Pain Syndrome
  • Symptomatic cardiovascular Disease
  • Cardiac pacemaker
  • Peripheral Arterial Occlusive Disease
  • Venous Thrombosis
  • Acute or recent Cerebrovascular accident, • Uncontrolled
  • Uncontrolled sizures
  • Raynaud’s Syndrome
  • Fever
  • Symptomatic lung disorders
  • Bleeding disorders
  • Severe Anemia
  • Infection
  • Cold allergy
  • Age of less than 14 year old (Parental consent needed for anyone under 18).

__ I have read and understand the contraindications to Whole Body Cryotherapy. (required)

Safety Instructions for Whole Body Cryotherapy:

  • You must be completely dry. Wet or sweaty skin will freeze.
  • All piercings below the neck must be removed or covered.
  • Thick socks, gloves, and footwear will be provided and must be worn at all times while in the machine.
  • Men MUST wear underwear during a session, cotton is highly recommended.
  • For women, clothing is optional. If wearing clothing please make sure it doesn’t have any exposed metal (clasps, buckles,etc).
  • During your session you must avoid inhaling the nitrogen fumes; while non-toxic, it is devoid of oxygen and can causing fainting.
  • You may end the procedure at any time if you experience any problems or anxiety.
  • Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, or medication. Consult you physician for more information.
  • Children under 18 may not use WBC without parental consent

__ I have read and understand the safety instructions for Whole Body Cryotherapy. (required)

Risks for Whole Body Cryotherapy:

  • Fluctuations in blood pressure:due to peripheral vasoconstriction, blood pressure may briefly increase by up to 10 points systolically during treatment. This effect should reverse after the end of the procedure, as peripheral circulation returns to normal.
  • Allergic reaction to extreme cold (rare)
  • Claustrophobia
  • Activation of some viral conditions (cold sores) etc. due to stimulation of the immune system.

__ I have read and understand the risks of Whole Body Cryotherapy. (required)

DECLARATION
I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the staff of my current medical or health conditions and to update this history as needed.

Halo

To help monitor your results please indicate which condition(s) apply to you (or your child):

__ Allergies
__ Asthma
__ Bronchitis
__ Cold & FluCystic Fibrosis
__ COPD
__ (desire to improve) General Wellness
__ Dermatitis
__ Ear Infection
__ (wish to) Increase Endurance
__ Eczema
__ Emphysema
__ Hay Fever
__ Enhanced Athletic Performance
__ Rhinitis
__ Psoriasis
__ Sinusitis
__ Sleep Apnea/Snoring
__ Smokers Cough
__ Stress
__ Detox
__ Other : _______________

 

__ I have been advised of the following possible side effects: Dry or itchy throat, nasal drip, and increased coughing at the beginning. This is a natural part of the cleaning process of the respiratory system, during which the pollution, accumulated through a long time, and now loosened up by the salt, are expelled from even the deepest regions of the lungs. Such side effects should cease with the removal of pollution and pathogens. Skin irritation and dermal sensitivity may occur. In such a case, decrease the frequency of sessions. (required)

__ The use of Halotherapy is not intended to treat, cure or prevent any illness or condition. All medical conditions should be treated by a physician competent in treating that particular condition. Do not stop your medication without first consulting with your doctor. The use of Halotherapy does NOT substitute for any conventional medication. The information contained herein is not intended to cover all possible uses, directions, precautions, warning, drug interactions, allergic reactions, or adverse effects. If you have any questions about Halotherapy check with your doctor before proceeding. Halotherapy is not recommended in the following cases: Tuberculosis, Fever, Contagious conditions, Severe heart disorders, Existence of cancer, Advanced pregnancy, and Acute state of respiratory attack. (required)

Sauna

We at Total Rejuvenation want to ensure a comfortable and safe infrared sauna experience.

  • No session will last longer than 45 minutes.
  • No clients under the age of 16 are permitted in the Sunlighten sauna unless accompanied by a supervising adult. All clients under the age of 18 must have a Guardian’s Signature.

Please read and consent to the following safety requirements:
__ I am not under the influence of drugs or alcohol. (required)
__ I am not pregnant (required)
__ If I feel light-headed, dizzy or heat exhausted I will discontinue the use of the sauna.(required)
__ I have been advised to drink plenty of water before and after my sauna session. (required)
__ I do not take any medications or I have consulted with my physician about my use of an infrared sauna. (required)
__ I have no medical history of circulatory system problems or I have consulted with my physician about my use of an infrared sauna. (required)