I certify I am over the age of 18
I have voluntarily elected to receive Cyrolipolysis (Cool Sculpting) after the nature and purpose of this treatment have been explained to me.
I understand that Cryo can be used to reduce fat deposits but it is not intended to be a weight solution.
I understand that there are no guarantees that the treatment will be effective and that to ensure maximum results, multiple treatments will be necessary.
I understand that the following conditions preclude me from having this treatment at this time and verify that none of the following conditions apply to me at this time:
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud's disease
Impaired peripheral circulation in the area being treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Impaired skin sensation
Open or infected wounds
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Skin conditions such as eczema, dermatitis or rashes
Any active implanted device such as a pacemaker and defibrillators
Pregnancy or lactation
I recognize there are no guaranteed results
I understand and acknowledge that are risks involved with the treatment I will be receiving including, but not limited to:
Puffing
Tugging
Pinching
Intense Stinging
Itching
Aching
Cramping
Bruising
Numbing
Muscle Spasms
Swelling
Tenderness
I have been informed of possible benefits, risks, and complications, and have had the opportunity to ask questions regarding these risks and other possible complications.
I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.
