Cryolipolysis Fat Freeze consent form

* Indicates required field

Cryolipolysis Fat Freeze consent form • Neuropathic (numbness) disorders, such as post-herpetic neuralgia or diabetic neuropathy; 麻木 • Cryoglobulinemia or paroxysmal cold hemoglobinuria, known sensitivity to cold such as cold urticaria or Raynaud’s disease 寒冷性荨麻疹 • Impaired skin sensation 受损皮肤感觉 • Open or infected wounds 伤口 • Bleeding disorders or concomitant use of blood thinners 出血性疾病、长期服用血薄药 • Recent surgery or scar tissue in the area to be treated 最近手术、疤痕组织等待治疗 • A hernia or history of hernia in the area to be treated or adjacent to treatment site (body part protrudes through the wall of muscle or tissue)身体部位突出肌肉或组织 • Skin conditions, such as eczema, dermatitis, or rashes 湿疹、皮炎、皮疹 • Varicose veins 静脉曲张 • Pregnancy or lactation 怀孕、哺乳期 • Any active implanted devices such as pacemakers and defibrillators 身体有起搏器、除颤器或任何机器 • Cardiovascular Illness 心血管疾病 • Liver Disease 肝病 • Kidney Disease 肾脏病 • Malignant Tumors 恶性肿瘤 • Diabetes 糖尿病 • Impaired peripheral circulation in the area to be treated 受损循环不良 *

I do not have any of the medical conditions stated above

Side effects • Redness 发红 • Firmness 坚固性 • Pinching sensation 捏感觉 • Swelling 肿胀 • Tenderness 压痛 • bruising 瘀血 • stinging 刺 • tingling 刺痛 • frost bite (very rare) 冻疮（少有） *

I'm aware of all the possible side effects stated above

Is this your first time doing Cryolipolysis fat freeze? *

If no, let us know the temperature you received on your last Cryolipolysis fat freeze *

I'm fully aware of all the side effects, Contraindications for Cryolipolysis fat freeze stated above. I'm fully aware of all the side effects which might occur during/after the treatment and I fully understand that all treatment results are not guaranteed, it's up to individual's recovery and different skin/body condition react differently. I'm not supposed to do any self treat after my treatment. Pure Element is not responsible for any touch up, sensitivity or side effects during/after the treatment. But we'll be there to advise you on what to do and make changes to your treatment if it's necessary. You'll never be alone. We'll always be there for you. Please check and make sure everything is good before you leave *

Yes I agree to the terms & condition stated above

Name *

First

Last

Last 4 digit of your NIRC *

Contact number *

Submit