Cryotherapy Consultation and Consent Form

Client Details

Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical History

Are you currently taking any medication? *

Please list: *

Do you have any allergies or intolerances? *

Please list: *

Are you currently, or possibly may be, pregnant? *

Do you suffer from any of the following conditions? Please tick all that apply.

Do you have any other medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide detail: *

Emergency Contact Details

Emergency Contact Name: *

Emergency Contact Relationship: *

Emergency Contact Phone: *

Consultation

Have you previously had Cryotherapy? *

What are your reasons for having Cryotherapy? *

What are your goals and expectations from Cryotherapy? *

Treatment Information

What is Cryotherapy?

Cryo comes from the Greek word 'cryo' and means cold. Cryotherapy refers to any form of medical treatment that relies on cold exposure. Whole Body Cryotherapy (WBC) is most commonly utilized in the field of sports medicine as a mode of muscle recovery and pain relief.

Whole Body Cryotherapy (WBC) involves immersing the body in a cold chamber, which emits vapors at extremely low temperatures ranging from -110°C to -160°C. This is usually done for an interval of 2 to 4 minutes.

How does Cryotherapy work?

When you step into the chamber, the temperatures drop drastically to unimaginable lows for a few minutes. However, the treatment and recovery process is quite straightforward.

When you step into the cryo chamber, the temperatures drop to as low as -160°c using our hybrid system combining the cooling power of liquid nitrogen and electricity. Once the temperature drops, you are expected to remain in the chamber for at least three minutes before you step out. Scientifically, this is concentrated and localised treatment method that is quite effective and more comfortable than jumping into an ice bath.

Once you step inside the chamber, the dry cold penetrates through your skin causing your body temperature sensors to send a quick signal to your brain which triggers a fight or flight response.

Blood Flow
When your brain sensors sense the extreme cold, it causes blood to flow to the torso to insulate and protect all the vital body organs. Once you step out of the chamber, a lot of oxygenated blood starts to rush to the body organs which help with the healing process. In theory, this makes sense, and that is what most people believe that happens.

Although this recovery method is still relatively new in the UK, it has been in use since the 1970s in Japan. Some people who suffer from severe joint pain, rheumatoid arthritis, and even depression claim that whole body cryotherapy help in alleviating their symptoms.

Athletes also claim that cryotherapy helps to improve their performance since it speeds up muscle recovery. Various studies have also proved that cryotherapy has an overall positive effect on soft body tissues and tend to slow down muscle soreness.

Possible Health Benefits of Cryotherapy:

Reduced inflammation (by increasing the presence of anti-inflammatory proteins and decreasing pro-inflammatory cytokine levels)
Reduced pain and improved joint mobility (by decreasing inflammation, improving antioxidant balance, and increasing beta-endorphins)
Improved symptoms of rheumatoid arthritis and multiple sclerosis (MS)
Reduced oxidative stress
Overall improved exercise performance and recovery

Safety Instructions for Cryotherapy:

You must wear gloves, socks and slippers in the chamber to avoid chilblain.
Treatments will be limited to 3 minutes to avoid overexposure.
During treatment, you must avoid inhaling the nitrogen fumes. Although non-toxic, they are devoid of oxygen and can result in fainting.
Do not dip your head down below the rim while in the chamber.
You must tell an employee if you feel anything is wrong and want to stop the procedure. You may end the procedure at any time, for any reason.
All metal jewellery and piercings from the jaw down are to be removed or covered before the session.

Consent

Please read each statement carefully and tick to show your agreement. *

I accept that any treatment I am going to receive is at my own risk. I certify that I have read and fully understood and completed this form to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect(s) and therefore I accept full liability/responsibility for the information given. The treatment(s) and possible side effect(s) have been fully explained to me. I accept full responsibility for the treatment given and complications which may arise or result during or following any procedure that is performed at my request. I accept that if I am not satisfied with the treatment I will inform the therapist and/or request to speak to the manager during or immediately following the treatment. I fully understand the above and consent to receive a Cryotherapy treatment.

Client Signature: *

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