Register for Your Appointment

Thank you for making your appointment at Help For Health.  When you come in you will be asked to submit some basic information and agree to  some simple service conditions to enable you to receive your requested treatment.  We request that you submit this basic information below, prior to your coming in to expedite your service.  Thanks for your help:

Submit Your Appointment Information to Us

You may register your appointment information with us by filling in this form.  Email or call us any time you need professional support or have any questions.

HELP FOR HEALTH

2800 Gallows Rd.

Vienna VA 22180

Phone: 703-644-4325

Fax: 571-425-4512

Enter your name:*
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Which Services do you require? Please check all that apply.
How many bowel movements do you have a day, a week or a month. Please list below:*
Please list medication, herbs or vitamins that you take below. Also list allergies and any exceptions that you have to the Colonic, Cryosauna, Liposaser or Vagisteam Terms and Conditions below. Also, please indicate if you are pregnant and provide the name and phone number of your primary physician below:
Name of person to contact in an emergency:*
Address:
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* Indicates required fields

COLON HYDROTHERAPY SAFETY AND PROCEDURES AGREEMENT

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Neither, HELP FOR HEALTH, nor its associates do the following things either implied or intended:

 

  1. We do not diagnose
  2. We make no attempt to cure or treat any condition.
  3. We make no claims or imply any claims to cure or treat any condition.
  4. We do not claim that any supplemental material we may speak about will cure any condition, or that its purpose is to treat any condition.
  5. We do not prescribe or treat disease, however, we do attempt to educate you in/on foods and a good diet and exercise if it is not contradictory to the recommendations of your primary health care provider or physician.

 

I, the undersigned client, understand the above statements, I, as the client, understand that diet and nutrition is considered to be an inexact science and that the results obtained are not always constant or predictable. I also understand that there is no guarantee of any results and the opposite of the desired results may appear. Whether or not I participate in colon irrigation is my decision, based on my constitutional right of the Ninth Amendment. I must make all decision relative to my well-being and health. I further understand that HELP FOR HEALTH, is not a medical facility and none of its associates are attempting to portray themselves or conduct the activities of medical doctors and I release the Technician, Facility and Manufacturer from any adverse effects I may incur by the use of colon irrigation. I also understand that the FDA Registered equipment used in this procedure is intended for use in Colon Irrigation, and colon irrigation has not been scientifically proven to provide any health or medical benefits and unproven claims of adverse events have been made in the past. I further understand that I am in full control of the colon irrigation. I receive and I may choose to stop the device at any time I want, at my own will, by closing the flow valve thus stopping the water.

 

I, the undersigned, am in full agreement that colon irrigation is not a proven method, cure or treatment of disease or condition nor has it been portrayed as such. Colon irrigation is a self-administered procedure where I, as the user of the device, am solely responsible for my own actions and releases the attending Technician, Facility and Manufacturer from any liability regarding my health issues. The device being utilized in the facility is a gravity device, where I will self-insert my own speculum and will be in full control of the procedure.

I further understand that HELP FOR HEALTH, nor any of its associates are NOT Medical Doctors and DO NOT diagnose, prescribe or claim to cure any ailments, conditions or disease.

All results are contributed to research and the utilization in future programs of self-health aid, while preventing my privacy, and waive any liability on behalf of the technician serving me.

PAYMENT IS DUE WHEN SERVICES ARE RENDERED. NO REFUNDS AFTER 24 HOURS. CREDIT CARD REFUNDS ARE SUBJECT TO A 6% REPROCESSING FEE. A MINIMUM 24-HOUR NOTICE IS REQUIRED TO CANCEL AN APPOINTMENT, OTHERWISE A $25 FEE WILL BE CHARGED.

CRYOSAUNA CLIENT INFORMATION SHEET
Whole Body Cryotherapy – WBC

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TERMS AND CONDITIONS FOR CRYOTHERAPY TREATMENT

Do you have any of the following: (please list those that apply in the window above)
1.  High blood pressure
2.  Any heart disorder, if yes, explain above.
3.  Asthma
4.  Shortness of breath
5.  Bleeding tendency
6.  Epilepsy
7,   Any other illness or disorder, if yes please explain above.

Have you had any of the following: (please list those that apply in the window above)
8.   Heart attack
9.  Stroke
10. Sudden loss of consciousness
11. Claustrophobia
12. Any surgeries (if yes when)

13.  Any serious injury (if yes where)
14.  Do you experience constant pain? (if yes, please explain)
15.  Do you feel well/healthy at the moment? (if no, please explain)

WHAT IS WHOLE BODY CRYOTHERAPY

Whole body cryotherapy is the exposure of a person’s skin to temperatures of -130 to -170 degrees Celsius (-238 to – 274 degrees Fahrenheit) for a short time (3 minutes or less). At this extreme temperature, the body activates several mechanisms that have significant long-term medical and cosmetic benefits:

Skin:
The outer skin is briefly “frozen” activating increased production of collagen in deeper layers of the skin (similar to laser treatments of the face, where very high temperatures are used). The skin regains elasticity and becomes smoother and even toned, significantly improving conditions such as cellulite and skin aging. Skin vessels and capillaries undergo severe vasoconstriction (to keep the core temperature from dropping), followed by vasodilation after the procedure. Toxins and other stored deposits are flushed out of the layers of the skin and blood perfusion is improved after several treatments. The anti-inflammatory properties of cryotherapy are also used to treat chronic skin conditions such as psoriasis and dermatitis.

Endocrine:
The extreme cold exposure causes the body to turn up its metabolic rate in order to produce heat. This effect lasts for 5-8 hours after the procedure, causing the body to “burn” 500-800 Kcal over the hours following the procedure. After several procedures, the increase in metabolic rate tends to last longer between treatments. Another “survival reaction” to the extreme temperatures is the release of endorphins (hormones) that have analgesic and anti-inflammatory properties, and improve mood disorders. Cryotherapy has been studied for the successful treatment of medication resistant depressive disorders. Patients furthermore experience a noticeable increase in libido, lending to the use of cryotherapy for ED and other sexual disorders.

Musculoskeletal:
The anti-inflammatory and analgesic properties of cryotherapy can drastically improve joint disorders such as rheumatoid and osteoarthritis. Athletes are using whole body cryotherapy to recover from injuries and improve their performance.

Immune System:
Cryotherapy improves the function of the immune system and decreases stress levels.

SAFETY INSTRUCTIONS FOR THE WHOLE BODY CRYOTHERAPY

• You must wear cotton or wool socks (and underwear for men) to avoid chilblain.
• Treatments are limited to 3 minutes per session. Overexposure to the cold temperatures may cause chilblain
• During the treatment, you must avoid inhaling the nitrogen fumes; while non-toxic, they are devoid of oxygen and may cause fainting.
• During treatment, you must keep your hands visible to the operator at the upper rim of the cryo-chamber as instructed.
• You may end the procedure at any time if you experience any problems or anxiety.
• Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, or medication, including but not limited to the following: (tranquilizers, high blood pressure medications)
• A person who is less than (18) years of age may not use whole body cryotherapy without parental consent.

CONTRAINDICATIONS TO USING THE WHOLE BODY CRYOTHERAPY

Pregnancy, severe hypertension (BP>180/100), acute or recent myocardial infarction (heart attack; need to be cleared for exercise), arrhythmia, symptomatic cardiovascular disease, acute or recent cerebrovascular accident (stroke; need to be cleared for exercise), uncontrolled seizures, fever, symptomatic lung disorders, bleeding disorder, infection, claustrophobia, intolerance to cold, age less than 18 years (parental consent to treatment), incontinence

RISK OF THE WHOLE BODY CRYOTHERAPY

Fluctuations in blood pressure (due to peripheral vasoconstrictions, blood pressure may briefly increase by up to 10 points systolically during treatment. This effect should reverse after the end of the procedure, as peripheral circulation returns to normal), allergic reaction to extreme cold (rate), claustrophobia, anxiety, activation of some viral conditions (cold sores) etc, due to stimulation of the immune system.

WAIVER OF LIABLILITY AND HOLD HARMLESS AGREEMENT

1. In consideration for using the cryo device (equipment), I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS Antra Truksane dba Cryolab California (hereinafter referred to as RELEASEE) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any damage or injury that may be sustained by me, while using the equipment or due to the use of the equipment or due to the use of the equipment.
2. I hereby confirm that no warranty or guarantee, or other assurance has been made to me covering the results of the cryo-process. I have been explained and understand the administration of the process, including possible adverse reactions, side effects, or other possible complications. It is understood that this CONSENT is being given in advance of any administration of the process, and is being given by me voluntarily to use the Equipment.
3. I am fully aware of the risks connected with the use of the Equipment, and I am voluntarily participating in said Equipment usage, and entering the above named premises to engage in such usage. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS that may be engaged in such an activity.
4. I further hereby AGREE TO IDEMNIFY AND HOLD HARMLESS the RELEASEE, from any costs that may incur due to the use of Equipment by me.
5. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and shall be deemed as a RELEASE, WAIVER, AND DISCHARGE of the above name RELEASEE. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of California.
6. I understand that the Equipment is designed for fitness and appearance enhancing use only by the persons in good general health. I have been advised that if I suffer from any medical condition or illness whatsoever, I am NOT TO USE the Equipment without my doctor’s written permission.
My signature below constitutes my acknowledgment that; (1) have read, understand, and fully agree to the foregoing CONSENT (2) the authorization and consent. The CONSENT shall stand as long as I use the Equipment at the location now and in the future. IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I have read and understand the foregoing Waiver of Liability 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 cryo device and that I am using these services at my own risk. I agree to use all sessions within the terms of the contract dates and understand that refunds are not given on unused portions of purchased packages.

LIPOLASER CONDITIONS OF USE

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The Lapex BCS LipoLaser is a new and innovative technology that has been designed for spot fat reduction and body contouring. Since its launch in the European and Asian markets in 2006 has been generating significant interest and has shown to be a very effective treatment.

The Lapex BCS LipoLaser is one of the tools that we can use to help you reach your goals and the real advantage of this technology lies in the fact that we can specifically target a trouble area. Once the fats have been released from the cell they can be used by the body as a fuel source. It is therefore critical that the dietary and lifestyle changes are made to help support the goals of treatment.

A reduced calorie diet and an exercise program that will help to burn approximately 350-500 calories post treatment are ideal. Individual results may vary and it is the responsibility of the client to ensure they are doing the appropriate home care to ensure maximum results. Clients should be consuming a caloric intake equivalent to their target weight (lbs) multiplied by 10. For example a 220lb male who wants to reach 200lbs, should be consuming a daily intake of 2000 calories. In some cases additional support may be required for lymphatic drainage to help stimulate the body to clear the fats that are released from the cell. Most clients experience a ½ inch reduction with each treatment and multiply inches can be lost with a series of treatment.

PATIENT AGREEMNT FOR LIPOLASER TREATMENT

in signing this agreement understand that I am beginning a series of treatments to help reach my goals of body contouring and spot fat reduction. I understand that individual results may and that I must commit to changing the dietary and lifestyle factors necessary to achieve optimal results. I understand that the first step to a positive change is creating awareness about the steps necessary to reach these goals, and will work diligently to ensure success.

I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I realize there may be pre-existing medical conditions that can preclude me from seeing optimal results. By signing this agreement I release the spa/clinic, manufacturer and distributors from any liability regarding this treatment and do so understanding that results can vary from one individual to the next.

I have read and fully understand this consent form and I realize I should not sign this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form.

If you have questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever, concerning the proposed treatment or other possible treatments, ask your doctor prior to signing this consent form.

PATIENT CONSENT FOR TREATMENT

Welcome and Congratulations!

This is an important decision towards improving your wellness and overall lifestyle!
We share the mutual desire of you reaching all of your wellness goals involving the BCS LipoLaser. In order for you to reach these goals, we have provided a few points to educate you on achieving your best results. It is important to manage your expectations according to an appropriate diet, lifestyle and exercise program incorporated in conjunction with your LipoLaser treatment protocol.

Ensure Your Best Results
• Drink plenty of water after every treatment
• Incorporate Whole Body Vibration (WBV) post treatment for 10 minutes
• Ensure you understand physical activity following each treatment to maximize your results
• Manage calories intake; excess calories will counter act the Laser Treatments
• Alcoholic beverages and high sugar content drinks must be avoided.

I hereby attest to the following (Please indicate any negative responses in the response box above):
1. The check mark above constitutes my acknowledgement that I am a competent, consenting adult of at least 18 years of age (or my parent or legal guardian) is giving consent on my
2. behalf), and further that I:
3. Have read and understand the information provided in this form.
4.  Have had my procedure adequately explained to me by my clinician.
5.  Have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
6.  Have received all of the information I desire concerning my procedure.
7.  Understand all post treatment recommendations and agree to adhere to them.
8.  Freely assume any risk of complications or injury from known or unknown causes
a. associated with, related too, or otherwise arising out of this procedure.
9.  Have the right to consent to or refuse any proposed procedure at any time prior to its performance.
10.  Must notify the clinician if my medical history changes prior to subsequent treatments.
11.  Consent to photographs of the treatment area.

CLIENT Confirmations:

I confirm, by my check mark above, the following (Please indicate any negative responses in the response box above):
1.  I am over the age of 18
2.  I am not pregnant or lactating
3.  I do not have epilepsy
4.  I do not have Herpes Simplex
5.  I do not have uncontrolled Hypertension
6.  I have no known liver or kidney disorders
7.  I have no known thyroid gland dysfunctions
8.  I do not have a compromised immune system
9.   I do not have cancer or a history of cancer
10.  I have no known photosensitivity to sun exposure
11.  I am not taking drugs that cause photosensitivity
12.  I consent to taking photographs and authorize their anonymous use for the purpose of medical audit, education, and/or promotion

I hereby understand the following limitation to Treatment:
1.  I understand there are no guarantees as to the results of this treatment
2.  I understand that to achieve maximum results, I may require several treatments
3.  It has also been recommended to achieve optimum results, I understand that an appropriate diet and regular exercise will assist to sustain and create a cumulative degree of overall spot fat reduction and body contouring.

I understand the following risks:
1.  temporary hyperpigmentation/hypopigmentation on rare occasion may occur as a result of treatment.
2.   I hereby certify that all information that I have provided has been accurate and truthful

I hereby authorize Help For Health to perform the LAPEX BCS LIPOLASER procedure for the purpose of aesthetic body contouring and girth loss.

PAYMENT POLICY

The following policy applies to all non-Groupon services:

PAYMENT IS DUE WHEN SERVICES ARE RENDERED.

NO REFUNDS GIVEN AFTER 24 HOURS OF PROVIDING SERVICES

CREDIT CARD REFUNDS ARE SUBJECT TO A 6% REPROCESSING FEE

A MINIMUM 24 HOUR NOTICE IS REQUIRED TO CANCEL AN APPOINTMENT, OTHERWISE A $25.00 FEE WILL BE CHARGED

V-STEAM SAFETY AND PROCEDURES AGREEMENT

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I confirm the following for the VagiSteam Treatment:

1. I am over the age of 18

2. I am not pregnant or lactating

3. I do not have open wounds, sores or blisters

 

Limitation to Treatment

4. I understand there are no guarantees as to the results of this treatment.

5. I understand that to achieve optimum results, I may require several treatments.

6. I hereby certify that all information that I have provided is accurate and truthful

The agreement checked above constitutes my acknowledgement that I am a competent, consenting adult of at least 18 years of age (If under 18, my parent(s) or legal guardian is giving consent on my behalf). (Please initial)

7. I have read and understand the information provided in this form.

8. I have had my procedure adequately explained to me by my clinician.

9. I have had the opportunity to ask questions; and all of my questions have been answered to

my satisfaction.

10. I have received all the information I desire concerning my procedure.

11. I understand all post treatment recommendations and agree to adhere to them.

12. I freely assume any risk of complications and/or injury from known or unknown causes

associated with and/or related to, or that arise out of this procedure.

13. I have the right to consent to or refuse any proposed procedure at any time prior to it’s

performance.

14.  I must notify the clinician if my medical history changes prior to subsequent treatments.

PAYMENT IS DUE WHEN SERVICES ARE RENDERED. NO REFUNDS AFTER 24 HOURS. CREDIT CARD REFUNDS ARE SUBJECT TO A 6% REPROCESSING FEE. A MINIMUM 24-HOUR NOTICE IS REQUIRED TO CANCEL AN APPOINTMENT, OTHERWISE A $25 FEE WILL BE CHARGED.

Disclaimer

The treatments presented are for the use of our patrons. We are a non-medical facility and do not claim to treat or heal any conditions.

Phone and email Contact Information

Toll Free: 1-409-4984 Local: 703-644-4325 Fax: 571-425-4512 Email: helpforhealth@aol.com

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Websites

www.helpforhealthnova.com www.helpforhealthnova.net www.helpforhealth.net
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