Cryoskin 3.0

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Children

Activity Level

Low
Moderate
High

Treatment of Interest

Skin Tightening
Cellulite
Slimming
Facial tightening
Brazilian Butt Lift
French Butt (less curvature)

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Please mark all areas of the body you are concerned with:


Background


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Have you had any other aesthetic procedure (s) before?
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How did you hear about Cryoskin 3.0?

TV
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Other
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Do you have any of the following: Please check ALL that apply:

Botox/Fillers ( Last 3 months)
Surgery ( last 3 months)
Breast Implants
Pregnant
Breast feeding
Cancer
Cold sensitivity (Reynaud’s)
In Vitro Fertilization (IVF)
Open or infected wounds
Scar tissue (in the area to be treated)
Eczema, rashes, or dermatitis
Circulation or heart disorders
Liver or kidney disease
Diabetes (type 1 insulin dependent)
Foreign ointments or lotions on the skin
Tattoo’s
Other
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Consent, Release and Indemnity Agreement

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The Cryoskin safely and effectively uses thermal shock to naturally destroy fat cells without any damage to the skin. The Cryoskin breaks down fat cells, which your body naturally flushes out through the bloodstream and then the lymphatic system in the days to weeks following the session. Cryoskin also helps to reduce the appearance of cellulite, fine lines and wrinkles by stimulating collagen and elastin production while tightening muscles. Cryoskin is also beneficial for facial toning and lifting. Protocols will be discussed and or adjusted during consultation based on recommendations and guest needs.


Initialsrequired

I understand that results may vary depending on individual factors including but not limited to medical history, prior treatments of area being treated, skin type, medication, hormones, patient compliance with pre/post session instructions and individual response to treatment. I understand that I must maintain good dietary habits, have sufficient water intake and participate in light physical activity as well as comply with other items outlined during consultation.


Initialsrequired

Photos will be obtained for records. If pictures are used for education and marketing purposes,, all identifying marks will be cropped or removed, unless the Cryoskin 3.0 treatment is done on the face. We only use the facial photo with your permission.


Initialsrequired

The completed form is for informational purposes only. The and its staff are not medical professionals, and do not claim to be. We are Cryoskin 3.0 experts and hold the highest standards of safety, customer service and education. The Cryoskin 3.0 products and equipment have not been tested or proved by the FDA or any other government agency for the treatment of any illness or disease. Use at your own risk.


Cryoskin should not be used on or applied to clients who have certain medical conditions and/or contraindications as listed below:

Contraindication

  • Cryoskin should not be applied over infected or swollen areas of the skin
  • Cryoskin should not be applied over or near cancerous areas

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Do you have cancer or a history of cancer?

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Are you undergoing active chemotherapy?

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Do you suffer from serious kidney disease?

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Are you on dialysis?

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Do you have any lymphatic drainage disorders?

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Have you had Botox or filler within 45 days?

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Do you suffer from Type 1 Diabetes?

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Question, condition, consent, etc.

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Do you have loss of sensation in your extremities?

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Are you pregnant, lactating or undergoing IVF?

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Do you suffer from Cold sensitivity or Reynauds?

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Recent surgery? (last 3 months)

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Do you have Eczema, Rashes, or dermatitis?

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Have you had breast augmentation or any other elective surgery?

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Do you currently have any open or infected wounds?

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Do you have any mesh inserts?

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Are you currently taking hormone therapy of any kind?

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The statements above are factual to my knowledge. I understand that any procedure involves risk. Risks may include redness, swelling, irritation, skin reaction, or increased heart rate. Some may experience delays onset muscle soreness from treatments on the stomach due to unintentionally engaging the abdominals, which disappear later the same day. I understand that each person has a different reaction to Cryoskin. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and receive satisfactory responses.


Initialsrequired

I agree to have my photograph taken to document my results. I give permission for any photographs and other audio-visual and/or graphic materials to be used for marketing, education, and/or promotional purposes without any payment to me. I understand that although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I might be identified by the photos.


Initialsrequired

By signing below, I, [ First Name ] [ Last Name ], acknowledge and certify that I have read and understand the “Consent, Release and Indemnity” agreement for this treatment, and that I am signing it voluntarily. Should any pain or discomfort occur, I will immediately notify the technician. I understand that I must be at least 18 years old to participate in this treatment. I understand that all sales are final and refunds are not permitted.


Date: 5/29/2019

Time: 2:42 PM

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Date: 5/29/2019

Time: 2:42 PM

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By clicking/tapping/touching/selecting or otherwise interacting with the "Submit" button below, you are consenting to signing this Document electronically. You agree your electronic signature ("E-Signature") is the legal equivalent of your manual signature on this Document. You consent to be legally bound by this Document's agreement(s), acknowledgement(s), policy(ies), disclosure(s), consent term(s) and condition(s). You consent to be legally bound by Waiver Master's policies, terms and conditions. You agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You may request a paper version of an electronic record by writing to us. We reserve the right to charge a reasonable fee for the production and mailing of a paper version of the record. Your current valid email is required for all communications.




Submission Sequence: 2019-05-29T20:43:21.929Z914
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