CryoSkin Consent
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" indicates required fields
Thank you very much for undergoing a CryoSkin procedure. We would like your procedure to have the maximum result with the maximum safety. Therefore, we kindly ask you to take some time to answer a few questions. The information below is for the CryoSkin operator's record only and will not be misused or passed on to any third parties, unless with authorization of the client.
Name
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First
Last
Date of Birth
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MM slash DD slash YYYY
Phone
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Email
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Permanent Contraindications for CryoSlimming or CryoToning/CryoFacial
If you have a specific condition that is not mentioned in the lists below, please inform your CryoSkin operator. Your CryoSkin operator might ask you for a medical consent or might refuse to conduct a CryoSlimming or CryoToning/CryoFacial as a precaution.
Do you suffer from cryoglobulinemia auto-immune disease?
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Yes
No
Do you suffer from allergies to cold (irritated skin, Raynaud syndrome)?
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Yes
No
Do you have any serious blood circulation conditions (phlebitis, thrombosis, severe varicose veins)?
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CryoSlimming or CryoToning are possible on spider veins without the initial warm phase
Yes
No
Do you have a hernia on the concerned area?
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Yes
No
Do you suffer from asteoporosis (level 3)?
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A cryofacial is possible on people suffering from asteoporosis.
Yes
No
Temporary Contraindications for CryoSlimming or CryoToning/CryoFacial
Are you under 18 years old?
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A session is possible for 16+ with parents consent.
Yes
No
Are you being treated for cancer at the moment?
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Yes
No
Are you pregnant or breast feeding?
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No CryoSlimming or CryoToning until the menses return or the end of breastfeeding. A CryoFacial is possible on pregnant/breastfeeding women.
Yes
No
Have you any skin condition on the concerned area?
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Wound, scar (less than 3 months), eczema, etc.
Yes
No
Have you recently had body piercing/tattoos on the concerned area?
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A procedure is possible is the area has completely healed; the piercing must be removed.
Yes
No
Contraindications for CryoSlimming (fat freezing) Only
Do you have any serious kidney or liver conditions?
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Yes
No
Are you diabetic?
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Session is possible after medical advice, with a session every 3 weeks
Yes
No
Do you have any implanted devices (Pacemaker, defibrillator...)?
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Session is possible after medical advice
Yes
No
What is the implanted device?
*
Have you had an organ transplant? Session is possible after medical advice
*
Yes
No
Please note that CryoSlimming is a technique to reduce localized body fat and loose inches/cm, it is not a solution to lose weight. It is possible to do a CryoSlimming session every 2 weeks (time necessary for the kidneys to eliminate the waste), all body zones included (it is not possible for example to do within 2 weeks a zone different that the first one). Please note that CryoSlimming is forbidden on the breasts and on the face. Sometimes localized redness can occur during the procedure, or the client might feel some discomfort or itching without consequences and sometimes due to the reactions with certain cosmetic products. These side effects usually disappear soon after the session. It is necessary to avoid eating sugar (including carbs), 2 hours before and 2 hours after a CryoSlimming session as sugar gives energy to the fat cells which are then more resistant to the procedure. After the session, it is recommended to drink a lot of water to drain the waste. Clients must follow a healthy diet and exercise to maintain results.
Contraindications for CryoToning/CryoFacial Only
Have you had Botox/hyaluronic fillers in the last 3 months?
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(CryoFacial Only)
Yes
No
Do you have any sinus sensitivity?
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(CryoFacial Only)
Yes
No
Do you have breast implants?
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(CryoToning targeting the breasts only)
Yes
No
Please note that it is possible to do a CryoToning/CryoFacial session every week on the same zone. It is possible to do more than one session per week on different zones.
For Marketing Use
I consent to the use of photos taken.
*
Yes
No
I consent to the use of photos taken, not showing my face.
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Yes
No
I consent to the use of photos taken, not showing my face but not my eyes.
*
Yes
No
I consent to the use of photos taken, showing parts of my face.
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Yes
No
I do not consent to any use of photos taken.
*
Yes
No
Acknowledgment
Disclaimer: I declare that I have read, understood, and answered the questions to the best of my knowledge. I have no known medical condition or allergies that may affect or induce a harmful reaction from a CryoSlimming (fat freezing) or a CryoToning/CryoFacial.
I agree
Date
MM slash DD slash YYYY
By typing your name below, you understand that there are no quarantees for results and all appointments from package(s) must be completed in 6 months for best results. Sessions are non-refundable.
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