04
Acknowledgment & Consent
About Pressotherapy
I understand that pressotherapy is a compression technique designed to help improve overall circulation and tone the circulatory system for faster detoxification and elimination, fluid clearance, slimming and firming, toning, and oxygenation.
How Compression Therapy Works
A computer controlled pump inflates the individual sections of a multichambered garment positioned around the limbs, inflating each chamber individually.
Contraindications
Contraindications for pressotherapy include: infection, open wounds, asthma, blood clots, pregnancy, severe eczema, deep vein thrombosis, cardiac heart failure, and pacemaker.
Treatment should not be administered while the client is taking medications for heart conditions, hemophilia, or asthma.
Acknowledgment of Risks and Indications
The details of the technique and its application were explained during my initial consultation, in addition to the written explanation above. I am fully aware of the small risks of treatment, including sensitivity reactions and minor bruising.
I understand that indications for use include secondary and primary lymphedema, post thrombosis edema, hypodermic inflammation, varicose or post thrombosis ulcers, lipodystrophy, and wrinkles.
I have disclosed all significant information regarding my medical history, have answered all health related questions truthfully, and will advise the service provider of any changes in my health.
Results, Confidentiality, and Assumption of Risk
During the consultation, it was explained that treatment results may vary from person to person, and no guarantees have been made to me.
All personal information in this consent will remain strictly confidential and will not be disclosed without my written consent.
I assume all risks involved and give consent for the duration of my treatment to all of the above. I have asked my personal primary physician any questions I have concerning the procedure and its risks.
I understand that I am obligated to advise the service provider of any changes in my medical condition for as long as I continue to receive the procedure. I am aware that the procedure may involve certain risks of injury.
Release of Liability
In consideration of Imagine Health's services in connection with the procedure, to the fullest extent allowed by law, I assume the risk of any and all accidents, illness, and injuries of any kind which may be sustained by me by reason of, or in connection with, the procedure.
In addition, I agree that, to the fullest extent allowed by law, neither Imagine Health nor any of its owners, agents, employees, personal representatives, successors, or assigns shall be liable or responsible for or on account of any such accident, illness, or injury, and I release, discharge, and absolve Imagine Health and its owners, agents, employees, personal representatives, successors, or assigns from any and all liability and responsibility for or on account of any such accident, illness, or injury.
Indemnification
To the fullest extent allowed by law, I shall indemnify, defend, and hold harmless Imagine Health and its owners, agents, employees, personal representatives, successors, or assigns from any and all losses, liabilities, damages, costs, and obligations (or actions or claims in respect thereof), including reasonable counsel fees, which they may suffer or incur, insofar as such losses, liabilities, damages, costs, or obligations (or actions or claims in respect thereof) arise out of, are based upon, or are in any way connected with the procedure.
Binding Agreement
This consent and agreement shall be binding upon my heirs, legatees, personal representatives, successors, and assigns.
By signing below, I acknowledge that I have read and fully understand the above statements. All questions regarding my care in this facility have been answered to my complete satisfaction. I therefore accept LymphoPro Lymphatic Massage Compression Therapy provided by Imagine Health on this basis.
