Recovery Lounge North Fork Consent Form

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Name *

Address *

Date of Birth *

YYYY

Email *

Emergency Contact

Name and Phone #

INFRARED SAUNA

Consent to use the infrared sauna is conditional upon provision of accurate answers to the following questions.

Please check the boxes next to the questions to indicate that your answer is "YES" for each one. If your answer is no for any of the below questions, please leave the box blank & explain in the next segment. *

I am not pregnant

I have not been diagnosed with a medical condition, such as anhidrosis, that may limit my ability to sweat

I do not have unstable angina

I am not taking any medications

I have not had a recent heart attack

I do not have a pacemaker or defibrillator

I do not have any other surgical implants (metal pin, rod, artificial joint, etc.)

I do not have severe arterial disease

I am not taking diuretics, barbiturates, beta-blockers or antihistamines

Required

If you did not answer "YES" to all of the above questions, please explain and indicate if you have been diagnosed with any other medical conditions:

If you have any medical conditions, have you consulted with your doctor and received authorization to use an infrared sauna? *

Yes

NORMATEC RECOVERY SYSTEMS (COMPRESSION)

The Normatec recovery systems are FDA cleared devices that are safe for use.

Do not use Normatec if you have any of the following conditions:

-Acute pulmonary edema

-Acute thrombophlebitis

-Acute congestive cardiac failure

-Acute infections Deep vein thrombosis (DVT)

-Episodes of pulmonary embolism

-Wounds, lesions, infection, or tumors at or near the site of application

-Where increased venous and lymphatic return is undesirable

-Bone fractures or dislocations at or near the site of application

I do NOT have any of the conditions mentioned above

I DO have one or more of the following conditions above

Required

JOOVV Red Light Therapy (PBM)

Light therapy is an effective treatment that’s widely studied, tested, and trusted by the world’s best.

Red Light

Delivered at 660nm, red light is readily absorbed by surface tissues and cells, leading to enhanced skin health and healing.

Near-Infrared Light

Delivered at 850nm, near infrared (NIR) light is invisible to the human eye, and penetrates into deeper tissues, leading to enhanced recovery and inflammation support.

Red light therapy treatment is NOT APPROPRIATE FOR THE FOLLOWING CONDITIONS: pregnancy, epilepsy, active cancer lesions, and anyone taking photosensitive medications.

It is highly recommended if you have any skin concerns that you speak with your doctor prior to doing PBM sessions.

By checking the box below, you acknowledge that you are aware of the contraindications and possible benefits and risks to the skin of PBM, and have spoken with your doctor and received authorization for treatment.

I acknowledge the above information and accept any and all potential risks of red light therapy (PBM).

Required

Recovery Lounge North Fork Acknowledgement

1. It is always important to maintain proper hydration before, during and after sauna use.

2.The use of drugs, medication or alcohol prior to or during sauna use may lead to dizziness or unconsciousness.

3.No one under the age of 18 is permitted in the sauna unless accompanied by a parent/guardian (Signature required).

4.Discontinue the use of the sauna if you feel light-headed, dizzy, or heat exhausted.

5.Sauna sessions are limited to one visit per day.

6.Water bottles are permitted in the sauna. No other food or drink is permitted in the sauna.

7.Use of personal electronic devices is not recommended in the sauna.

8.Clients using any medications, and pregnant women, must consult a physician or pharmacist prior to sauna use.

By typing my name below, I am acknowledging and voluntarily assuming all risk of injury, accident or death which may arise from use of the sauna. I and any of my heirs, executors, representatives, or assigns hereby release all claims or liabilities for personal injury or property damage of any kind while on the premises, during the use of the sauna, compression sleeves, JOOVV red light therapy, CVAC machine, NuCalm, or any other offered modalities I choose to utilize, and from any advice provided by an employee, independent contractor or any representative. I agree that this application and waiver is in effect for all visits and sessions at the Recovery Lounge North Fork and will not expire unless specifically requested in writing by either party.
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