Wavier & Release

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Client Consent and Liability Waiver

This adult client waiver covers ReliefMed, RecoverMed, RestoreMed, and Frotox offered by SYNERGY CENTER LLC through Recovery Room. It includes cryotherapy, red light, vibration, and targeted muscle frequency release. Select the services for your visit below. Read all sections and ask questions before signing.

Legal business entity: SYNERGY CENTER LLC

Client full name Date of birth Phone Appointment date Emergency contact and phone

Selected services

ReliefMed RecoverMed RestoreMed Frotox

Localized cryotherapy Red light Vibration Targeted muscle frequency release

Treatment area

Health screening

Mark Yes or No for each item. A Yes answer requires staff review before treatment; it does not automatically mean treatment is appropriate or prohibited. Screening must also follow the exact device instructions and provider protocol.

Cold allergy or hives, Raynaud disease, cryoglobulinemia, or other cold sensitivity Yes No

Poor circulation, vascular disease, neuropathy, diabetes, or reduced skin sensation Yes No

Heart disease, arrhythmia, uncontrolled blood pressure, stroke, or fainting history Yes No

Pregnancy, possible pregnancy, or recent childbirth Yes No

Blood clot or suspected clot, bleeding disorder, or blood thinning medication Yes No

Recent surgery, fracture, significant injury, spinal procedure, or implanted hardware Yes No

Pacemaker, defibrillator, or other implanted electronic device Yes No

Open wound, infection, rash, active skin disease, or suspicious skin lesion Yes No

Light sensitivity, photosensitive condition, or photosensitizing medication Yes No

Seizures, balance problems, or inability to stand safely on a vibration platform Yes No

Recent Botox, filler, laser, peel, facial surgery, or other cosmetic procedure Yes No

Explain Yes answers and other medical conditions Medications and supplements Allergies

Treatment Information and Risks

Nature and limits of services

These are elective wellness and cosmetic services. Service names do not establish physician involvement. They do not replace medical diagnosis, rehabilitation, emergency care, or prescribed treatment. Localized cryotherapy uses controlled cold exposure; red light uses light exposure; vibration uses a moving platform. Targeted muscle frequency release must be explained using the actual device and technique before consent.

For Frotox, no botulinum toxin is administered. Research does not establish that a routine cryofacial produces lasting wrinkle reduction or skin tightening. Cosmetic changes may be temporary, and no particular outcome, collagen increase, pain relief, performance improvement, or nervous system effect is guaranteed.

Cryotherapy risks

Cold discomfort, redness, numbness, irritation, hives, dizziness, and changes in skin color may occur. More serious risks include cold burns, frostbite, blistering, tissue or nerve injury, and scarring. Facial exposure can injure eyes if protection and technique are inadequate. Device type and exposure settings affect risk; some cold delivery systems also require ventilation precautions.

Red light risks

Possible effects include warmth, redness, dryness, irritation, headache, or aggravation of a light-sensitive condition. Improper use may cause burns or eye injury. I will disclose medications and light sensitivity and use the eye protection specified for the device.

Vibration risks

Possible effects include dizziness, loss of balance, falls, nausea, headache, soreness, or aggravation of an existing joint, spinal, or other injury. I will use support as directed and report discomfort immediately.

Targeted muscle frequency release

Device and technique completed by staff Operator completed by staff

Staff must explain the exact method, relevant contraindications, and risks before it is used. Depending on the method, discomfort, bruising, soreness, skin irritation, muscle contractions, or symptom aggravation may occur. Electrical or electromagnetic methods can introduce additional risks involving implanted devices; mechanical or manual methods have different risks. My signature does not consent to an unexplained technique.

Additional device specific risks and precautions

Alternatives and my right to stop

Alternatives include declining treatment, delaying treatment, or seeking evaluation and treatment from a licensed health professional. I may stop any service at any time. I will immediately report burning, sharp pain, excessive numbness, dizziness, breathing difficulty, chest pain, or visual symptoms. Staff may modify or stop a session for safety. Persistent or severe symptoms require medical evaluation.

Client initials

I understand the risks and limits described in this section.

Consent and Limited Liability Release

My disclosures and responsibilities

I am at least 18 years old. I have answered honestly, disclosed relevant health conditions and medications, and will report changes before future sessions. I am not impaired by alcohol or other substances. I understand that a completed form or clinician clearance does not guarantee safety. I agree to follow instructions, use required protective equipment, and tell staff immediately about discomfort or unexpected symptoms.

Voluntary consent and assumption of risks

I have had the opportunity to ask questions and receive understandable answers about the selected services, expected experience, risks, and alternatives. I voluntarily consent only to the services selected and explained to me. I understand that known risks may occur despite reasonable care, and I voluntarily accept those disclosed risks. I may withdraw consent at any time.

Limited release of ordinary negligence claims

TO THE EXTENT PERMITTED BY ARIZONA LAW, I RELEASE SYNERGY CENTER LLC, ITS OWNERS, EMPLOYEES, AND CONTRACTORS PROVIDING THE SELECTED SERVICES FROM CLAIMS FOR PERSONAL INJURY OR PROPERTY DAMAGE ARISING FROM MY PARTICIPATION CAUSED BY THEIR ORDINARY NEGLIGENCE, INCLUDING NEGLIGENT INSTRUCTIONS OR EQUIPMENT OPERATION. I UNDERSTAND THIS CLAUSE IS INTENDED TO LIMIT MY RIGHT TO RECOVER DAMAGES FOR SUCH ORDINARY NEGLIGENCE.

This release does not apply to gross negligence, reckless or intentional misconduct, or any claim or right that cannot lawfully be waived. It does not excuse unsafe practices or waive my right to report concerns to regulators or seek emergency care. Enforceability remains subject to applicable Arizona law. No promise is made that this release will prevent a claim or be enforced.

Client initials

I have read and understand the limited release above.

Agreement and signatures

This form applies to the services identified for this visit. Before later visits, staff will confirm current health information and consent. Material changes in services, equipment, technique, or risks require an updated explanation and consent. If a provision is unenforceable, other provisions remain effective to the extent allowed by law. This document does not change my payment or refund terms or authorize marketing use of my information or photographs.

I have read all sections, understand this agreement, and sign voluntarily. I may request a copy.

Client printed name

Client handwritten signature

Signature date Signature time

Staff printed name and handwritten signature

Staff signature date

Staff review

Health screening reviewed Device precautions checked Questions answered Clearance obtained if indicated Treatment deferred

Visit notes or changes

For appointments, text (808) 938-0040. Please do not text this form or your medical history.

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