Are you currently taking any of the following medications?:
I understand the above information and guarantee that it was completed to the best of my knowledge. I understand it is my responsibility to inform this office of any changes in my medical status.
Any of the below described advisements and contraindications will require you to use discretion for your own well being. In addition, PLEASE BE AWARE, that if you experience any pain or mental or physical discomfort at any time during the process, you are advised to terminate the session immediately upon your own volition. If you have severe medical conditions (i.e., Cancer) we recommend discussing this service with your doctor and may require a note of authorization prior to the use of Compression Therapy.
Contraindications: (Participation in Compression Therapy not allowed):
• Current or unstable fractures or breaks,
• Recent surgery with sutures or stitches,
• Open wounds, contusions, or abrasions (including sutures or stitches)
• Acute infections or irritation of the skin at the site of compression application
• Suspected or known deep vein thrombosis (current or past diagnosis)
• Severe atherosclerosis or other ischemic vascular diseases
• Severe congestive cardiac failure
• Existing pulmonary edema
• Existing pulmonary embolism
• Extreme deformity of the limbs
• Acute thrombophlebitis
• Any local skin or tissue condition which the garments would interfere with such as gangrene, untreated or infected wounds, recent skin graft, lesions or tumors and dermatitis
• Known presence of malignancy in the legs
• Limb infections, including cellulitis, that have not received antibiotic coverage
• Presence of Lymphangiosarcoma
● Post-Surgery (Surgeon Clearance before service)
● Muscle Tears or Scar Tissue (Start at a low intensity level and stop treatment if discomfort or pain occurs)
I have read and fully understand the above information.
Any of the below described advisements and contraindications will require you to use discretion for your own well-being. In addition, PLEASE BE AWARE* that if you experience any pain or mental or physical discomfort at any time during the process you are advised to terminate the session immediately upon your own volition. If you have severe medical conditions (ie. Cancer) we recommend discussing this service with your doctor and may require a note of authorization prior to the use of the PBM Therapy.
AdvisementsEye Safety - Do not stare directly into the diodes or its reflection in a mirror because it may cause temporary irritation of the eyes.
Cancer - Users with cancer or history of cancer should consult their physician prior to use.
Post-Surgery - Post-surgery users should consult a physician prior to use.
Open Wounds - Do not use the device on open wounds, as heat may increase circulation and cause bleeding.
Heat-Producing Ingredients - Do not use this device in combination with liniments, salves, ointments and balms that contain heat-producing ingredients as a skin burn could result.
Diabetes - It is conceivable that this treatment may reduce medication requirements.
Monitor blood sugars regularly and notify physicians of any changes.
Hyper-Pigmentation - Near Infrared (NIR) at 850 nm may aid hyper-pigmentation. Discontinue use if this is a concern.
Hair Regrowth - Users who have had laser hair removal could experience hair regrowth
Hyperthyroidism - Users with hyperthyroidism should consult with their physician prior to use, as use could increase symptoms.
Tattoos - Users with black pigmented tattoos could experience skin blistering. Blistering can occur by inadvertent heating of the iron oxides and/or the metal salts in the tattoo's black pigment. Tattoo locations can be covered prior to your treatment.Herpes - Users with herpes virus could experience activation of dormant virus with use.
Light Sensitivity - If you take medications or have conditions that may be affected by light, notify your health professional before beginning your PBM Therapy session.Pins/Plates/MetaI Implants/Pacemakers - There is no evidence of adverse effects for patients with these devices.
Children - Consult with the child's Pediatrician before use. Children under the age of 12 must be accompanied by an adult.
Reactions to PBM Therapy - Very occasionally some customers may suffer a slight increase in pain - customers should be warned of this possibility prior to LED treatment. This is not necessarily an adverse reaction and may be a consequence of increased blood flow or change in metabolic activity that subsides in 24 - 48 hours.
Certain Medications - Users taking medications such as Tetracycline, Digoxin, Retin A, and/or other photosensitive drugs, are recommended to consult with their healthcare provider prior to use.
Facial Fillers/Botox - Users with a history of facial fillers and botox injections should consult their dermatologist prior to use.
Breast implants - Users with breast implants should consult their plastic surgeon prior to use.
Contraindications:● Do not use the device if you are photosensitive.● Do not use if you have epilepsy or a history of seizures.● Do not use the device if using topical, oral, or injectable steroids.● Do not use the device during the healing period post Lasik eye surgery.● Do not use the device if pregnant or lactating, users should consult their physician with any questions.
Any of the described contraindications will require you to use discretion for your own well being. In addition, PLEASE BE AWARE, that if you experience any pain or mental or physical discomfort at any time during the process, you are advised to terminate the session immediately upon your own volition. If you have severe medical conditions (i.e. cancer) we recommended discussing this service with your doctor and may require a note of authorization prior to the use of the Infrared Sauna.
Medications:Diuretics, barbiturates and beta-blockers may impair the body’s natural heat loss mechanisms. Anticholinergics such as amitriptyline may inhibit sweating and can predispose individuals to heat rash or to a lesser extent heat stroke. Some over-the-counter drugs, such as antihistamines, may also cause the body to be more prone to heat stroke.
Pregnancy:If Pregnant do not use the Infrared Sauna.
Breast Feeding:If breastfeeding, do not use the Infrared Sauna. A detoxification process will produce the expelled toxins into your breast milk.
Menstruation:Heating of the low back area of a woman during the menstrual period may temporarily increase their menstrual flow.
Elderly:The body must be able to activate its natural cooling processes in order to maintain core body temperature. As we mature, our bodies naturally lose this capability. Guests over the age of 70 will be permitted for Infrared Sauna use, however, at a lower temperature.
Children Ages 12-17:The core body temperature of children rises much faster than adults. This occurs due to a higher metabolic rate per body mass, limited circulatory adaptation to increased cardiac demands and the inability to regulate body temperature by sweating. Consult with the child’s Pediatrician before using the sauna. Children under the age of 12 are not permitted to use the Infrared Sauna. Anyone between the ages of 12 and 17 must be accompanied by an adult.
Cardiovascular Conditions: Individuals with cardiovascular conditions or problems (hyper/hypotension), congestive heart failure, imparied coronary circulation or those who are taking medications which affect blood pressure should exercise caution (except where explicitly contraindicated below) when exposed to prolonged heat. Heat stress increases cardiac output and blood flow in an effort to transfer internal body heat to the outside environment via the skin (perspiration) and potential to increase by thirty (30) beats per minute for each degree increase in core body temperature. A lower temperature request can be accommodated. Decompensating Disease (Edema) of the Cardiovascular and Respiratory System: Individuals with edema of the cardiovascular and respiratory system may not use the Infrared Sauna.
Alcohol/Alcohol Abuse:Contrary to popular belief, it is not advisable to attempt to “sweat out” a hangover. Alcohol intoxication decreases a person’s judgement; therefore, he/she may not realize when the body has a negative reaction to high heat. Alcohol also increases the heart rate, which may be further increased by heat stress. Guests who appear intoxicated or inform us of alcohol consumption prior to use of the sauna will forfeit their scheduled appointment and no refund or credit will be issued.Chronic Conditions/Diseases Associated With Reduced Ability to Sweat or Perspire: Multiple Sclerosis, Central Nervous System Tumors and Diabetes with Neuropathy are conditions that are associated with impaired sweating.Hemophiliacs/individuals Prone to Bleeding:The use of infrared saunas should be avoided by anyone who is predisposed to bleeding.
Fever:An individual who has a fever should not use an infrared sauna until the fever subsides.
Insensitivity to Heat:An individual with insensitivity to heat should not use an infrared sauna.
Joint Injury: If you have a recent (acute) joint injury, it should not be heated for the first 48 hours after an injury or until the swollen symptoms subside. If you have a joint or joints that are chronically hot and swollen, these joints may respond poorly to vigorous heating of any kind.
Implants:Metal pins, rods, artificial joints or any other surgical implants generally reflect infrared waves and thus are not heated by this system. Nevertheless, you should consult your physician prior to using an infrared sauna.
Pacemakers/Defibrillators: Dependent on the type of infrared sauna, the magnets used to assemble infrared saunas can interrupt the pacing and inhibit the output of pacemakers. It is not recommended that you use the infrared sauna.
In the rare event that you experience pain and/or discomfort, immediately discontinue sauna use, and exit the sauna.
Hyperbaric Oxygen Therapy has been reported to have beneficial effects for a wide range of conditions, without negative side effects that can be harmful to your health. Nevertheless, as with many treatments there are areas of concern which you should be aware of. It is important that you take a few minutes to read the following information.
OTIC BAROTRAUMA is a condition of injury to the eardrum, and is extremely unlikely to occur in the hyperbaric chamber. However, severe ear discomfort can be caused if you cannot equalize the pressure in your ears. As the chamber is pressurized and depressurized you must be able to equalize the pressure in your ears to acclimate to the pressure changes. You will most likely experience a “popping” in your ears. This is normal.
You can assist the equalization process by yawning, swallowing, working your jaw side to side and up and down (chewing motion), turning the head side to side and ear to shoulder. Sitting upright in the chamber during pressurization and depressurization will generally also make the equalization process more comfortable. In general, whatever assists you being comfortable when taking off and landing a plane may be most effective for you. Continue to do this as needed for the duration of pressurization and depressurization. When the chamber reaches full pressure and again when the chamber is completely deflated there should be no additional pressure in the ears.
IF YOU ARE UNABLE TO EQUALIZE EAR PRESSURE AND EXPERIENCE PAIN IN ONE OR BOTH EARS, COMMUNICATE ANY DISCOMFORT IMMEDIATELY TO THE STAFF.
This will give us the opportunity to make adjustments in the pressurization or depressurization process to eliminate discomfort.
EAR, SINUS AND/OR THROAT CONGESTION, HEAD COLDS, VIRUS, OR PRIOR TRAUMA TO THE EARS: You may consider rescheduling your visit in the chamber if you are suffering from any of these conditions. Discomfort from these conditions is less frequent but may occur.
MEDICATIONS: Hyperbaric Oxygen Therapy may enhance the effectiveness of any medication you are taking. IT IS RECOMMENDED THAT YOU HAVE THE DOSAGE AND FREQUENCY OF ALL MEDICATIONS MONITORED AND ADJUSTED REGULARLY BY YOUR PHYSICIAN.
SEIZURES: Hyperbaric Oxygen Therapy is not associated with causing or inducing seizures. IF ANYONE GETTING IN THE CHAMBER IS SEIZURE PRONE, THE STAFF MUST BE MADE AWARE PRIOR TO THE FIRST VISIT. If a seizure is experienced in our clinic, unless otherwise instructed and a waiver is signed, our procedure is to call 911, remove the patient from the chamber and make the individual as comfortable as possible.
DETOXIFYING OR CELL DIE OFF: Hyperbaric Oxygen Therapy may assist the body to naturally detoxify and balance digestive flora. AN INDIVIDUAL MAY EXPERIENCE SOME DISCOMFORT FROM THIS PROCESS IN AS LITTLE AS ONE TO THIRTY SIX HOURS AFTER TREATMENT. Symptoms may include: flu-like symptoms, loss of appetite, stomach ache, constipation, diarrhea, headache, behavioral issues, etc. Although unpleasant, this is a natural process and continuing treatments may be of benefit to more rapidly accomplish a positive result. HOWEVER, IF SYMPTOMS PERSIST, WE RECOMMEND CONSULTING YOUR PHYSICIAN TO EVALUATE AND ALLEVIATE THE SITUATION BEFORE ATTEMPTING ANOTHER VISIT.
DIABETES / INSULIN DEPENDANT: Insulin dependency may result in a drop in blood sugar while in the chamber. IMMEDIATELY COMMUNICATE TO THE STAFF IF YOU EXPERIENCE OR ANTICIPATE AN EPISODE - YOUR TREATMENT WILL BE TERMINATED. Please take a protein bar and a juice box or whatever you use if faced with a “drop” in the normal management of your condition into the chamber with you.
SENSITIVITY TO CHEMICALS (MCS) / ODORS/ ALLERGIES: Please avoid wearing heavy colognes and the smells may linger in the chamber and have an adverse effect on another client.
PREGNANCY: HYPERBARIC OXYGEN THERAPY IS NOT ALLOWED DURING THE FIRST TRIMESTER. After this time it may be beneficial to both mother and child. A doctor’s prescription will be required for treatment.
PNEUMOTHORAX: Hyperbaric Oxygen Therapy is contraindicated for an existing Pneumothorax (collapsed lung). If you have experienced a Pneumothorax in the past and have already been “cleared from your doctor” to resume normal activity, once you provide a written confirmation you should be able to proceed with Hyperbaric Therapy.
IF YOU HAVE OR SUSPECT YOU HAVE: Hereditary Spherocytosis, Sickle Cell Anemia, COPD, or Compressive Brain Lesion (subdural hematoma or intracranial hematoma) you must have a doctor’s clearance before use of the chamber.
Hyperbaric Oxygen Therapy is CONTRAINDICATED for EXISTING Compressive Brain Lesions.
If you are uncomfortable in any way, or have any questions during your treatment session, you need to report them to the chamber operator immediately.
This is a release of liability and a waiver of certain legal rights. I hereby have read the advisements and contraindications and give my consent to using the Compression Therapy ("Compression Therapy"), Photobiomodulation (“PBM Therapy”), Infrared Sauna (“IR Sauna”), and/or Hyperbaric Oxygen Chamber Therapy (“HBOT”) at Ultimate Sports. I have no conflicts for use as described in the considerations and contraindications below.
I understand that this service is not intended to take place for medical care or medications. I confirm that I do not have any contraindications for Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT as outlined below. I understand that I take full responsibility for my own health and well-being.
I understand the purpose of Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT. I understand that the practice of medicine is not an exact science and I acknowledge that no guarantee can be made as to the outcome of the Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT.
I understand that my participation in Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT provided by Ultimate Sports is voluntary and I have the right to halt the service at any time. In consideration for being serviced by Ultimate Sports for any of its services including Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT, I hereby waive any and all claims and damages for personal injury and/or death which may occur as a result of my participation. I understand and agree that:
The release is intended to discharge in advance Ultimate Sports, Orr Training & Therapy Services, LLC, Garcia Integrated Health, Integrated Sports, LLC,its affiliates, owners, officers, employees, and agents from and against all liability arising out of or connected in any way with my participation and/or receipt in these services;
I acknowledge that adverse reactions may occur. In exchange of the Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT services offered by Ultimate Sports I hereby indemnify and hold harmless Ultimate Sports, Orr Training & Therapy Services, LLC, Garcia Integrated Health, Integrated Sports, LLC, its affiliates, owners, employees and agents from any loss, liability, damage, cost or expense, including litigation of any form, arising out of or connected in any manner with my participation in such activities;Participation may involve risk of serious injury, illness, disability and/or death and may result not only as a result of my actions, negligence or inaction, but also from the action, negligence or inaction of others, including their owners, officers, employees or agents, may result from the conditions of the facilities or areas where such activities are being conducted;
I am in good health and have no physical condition which would preclude me from safely participating in such activities;I understand and agree that this release is intended to be broad and inclusive as permitted under applicable state law and that if any portion of this waiver should be determined invalid, it is my intent that the remaining provisions shall continue in full force and effect.My signature below constitutes acknowledgement that I have read and agree to the above, and that an Ultimate Sports employee has satisfactorily explained Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT and that I have all the information that I desire. I hereby voluntarily request permission and give my authorization and consent to participate in Compression Therapy, PBM Therapy, IR Sauna, and/or HBOT at Ultimate Sports.
Health-information-Authorization - I authorize Ultimate Sports to use and/or disclose protected health information in accordance with the following:
● I give permission to Ultimate Sports to use my address, phone numbers and medical health records I provide to contact me with appointment reminders or notifications and to discuss any and all information about me and my services received, medical condition(s) and/or related topics to any Ultimate Sports healthcare professionals and employees who assist those healthcare professionals.
● I am also aware and give permission that other customers and employees overhear some of my protected health information during the course of my services. Therefore, I release Ultimate Sports from any and all state or federal statutes relating to patient privacy. Should I need to speak with the tech in private I will request and subsequently be given a room for these conversations.
● I am also aware that I may ask to read Ultimate Sports Privacy notice regarding my rights to my health information.
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:
● I should always seek the advice of a doctor or other qualified health professional with any personal medical and health questions that I may have before beginning any exercise or treatment program.
● I agree to consult my physician before continuing an exercise or treatment program if there is any change in my medical condition.
In the rare event that you experience pain and/or discomfort, immediately discontinue Compression Therapy, PBM Therapy, IR Sauna, or HBOT use.
I acknowledge that I am signing as myself and/or as guardian on behalf of a child who is under 18 years of age (IR Sauna child must be 12 yo or older):