Waiver of Liability, Release and Hold Harmless Agreement:
In consideration for using the NormaTec Recovery System I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS Rapid Recovery Solutions LLC, its owner and employees from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, that may be sustained by any person, while using the equipment or due to the use of the equipment at R2 Recovery Lounge.
Contraindications:
NormaTec® Compression Therapy is contraindicated for patients with:
· Current or unstable fractures/breaks
· Recent surgery and have sutures/stitches
· Open wounds, contusions, abrasions
· Suspect or known Acute deep vein thrombosis (DVT) (blood clot)
· Severe atherosclerosis (disease of the arteries)/Ischemic vascular disease (IVD)
· Severe congestive cardiac failure (CHF)
· Existing pulmonary edema (having excess fluid in the lungs)
· Existing pulmonary embolism (blood clot in the lungs)
· Extreme deformity of the limbs
· Any local skin conditions such as gangrene, untreated or infected wounds, recent skin graft, or dermatitis
· Known presence of malignancy in the legs or arms
· Limb infections, including cellulitis that have not been treated
· Presence of Lymphangiosarcoma (a rare cancer due to long-standing lymphedema of the upper/lower extremities)
Patient’s Consent:
My signature constitutes my acknowledgment that (A) I have read, understand, and fully agree to the foregoing CONSENT, (B) the proposed usage of the NormaTec equipment has been satisfactorily explained to me and I have all of the information I desire and (C), I hereby give my authorization and consent. This CONSENT shall stand as long as I use the NormaTec equipment at R2 Recovery Lounge now and in the future. I have read the instructions for proper use of the facilities and do so at my own risk and hereby release R2 Recovery Lounge from any damage or harm that I might incur due to use of the NormaTec equipment.
IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read and understand the foregoing Waiver of Liability, release and Hold Harmless Agreement, I am at least eighteen (18) years of age and fully competent; and I execute this Release for full, adequate, and complete consideration fully intending to be bound by same. Furthermore, I agree that I will comply with all instructions on the use of the Equipment and that I am using these services at my own risk.
DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM. You have the right to withdraw consent for this procedure at any time before it is performed. Minors require a parent/guardian signature.
Patient or Authorized Representative
