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Form 3 of 3

NormaTec® Compression Therapy Waiver

Required for any compression therapy session. Please review the contraindications, then sign at the bottom. Minors need a parent or guardian signature.

Physical Capability Requirements

Participation in a NormaTec® Compression Therapy session involves exposure to vasopneumatic compression for a short period of time. During the compression therapy, a Health & Wellness practitioner will be present. You are free to terminate the session at any time.

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 (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)

In consideration of being permitted by DWT Wellness to participate in their services for NormaTec® Compression Therapy, I hereby state that I understand it may aggravate a pre-existing medical condition, or could lead to injury. I am voluntarily assuming all risks of accident or injury to me (or my child) arising out of or in any way connected with the use of the services, equipment, or facilities at DWT Wellness.

I hereby release DWT Wellness, Wellness Within Chiropractic, and its staff members, officers, directors, and agents of all liability for any damage, injury, or harm which may be caused by, a result of, or in any way associated with participation in this service of DWT Wellness & Wellness Within Chiropractic as a guest or member.

I acknowledge that I am at least 18 years of age and have read, understand, and agree to this Release Statement, that it is an informed release, and that I intend to be legally bound to it. By submitting this form, I agree to the terms listed on the session and media release waiver. I am opting in to receiving promotional and/or follow-up text messages. Minors require a parent/guardian signature.

Your information

First Name
Last Name
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code

Format: (000) 000-0000

Signature

Sign with your finger, stylus, or mouse.

Parent / Guardian (for minors only)

Read and sign this section only if the participant is under 18. I am the parent or guardian of the minor whose name and signature appears above. I have carefully read this agreement and fully understand its contents. I acknowledge that this release of liability is a legally binding contract between DWT Wellness and me.

First Name
Last Name

Sign with your finger, stylus, or mouse.