Aspley Cryolipolysis Treatment Consent Form

The Cryolipolysis procedure is a non-invasive treatment that uses a vacuum applicator to draw in tissue and deliver controlled cooling at the surface of the skin. This procedure is for spot reduction of fat and does not replace traditional methods such as liposuction. It should not be used as weight-loss solution.

Someone who is overweight can expect to see less visible improvement than someone who has smaller fat deposits. Clinical studies have shown that Cryolipolysis will naturally remove fat cells however, as with most procedures, visible results will vary from person to person.
Name

First NameLast Name
Address:
Phone:
E-mail
DOB:
Medical Conditions:
Medications:
Allergies:
Are you pregnant or breasfeeding?
Have you had any of the following conditions, tick all that apply

Cryoglobulinemia or paroxysmal coldhemoglobinuriaKnown sensitivity to cold such ascold urticaria or Raynaud’s diseaseImpaired peripheral circulation in the area to be treatedNeuropathic disorders such as post-herpetic neuralgia or diabetic neuropathyImpaired skin sensationOpen or infected woundsBleeding disorders or concomitant use of blood thinnersRecent surgery or scar tissue in the area to be treatedA hernia or history of hernia in the area to be treated or adjacent to treatment siteSkin conditions such as eczema, dermatitis, or rashesPregnancy or lactationAny active implanted devices such as pacemakers and defibrillatorsLiver or Kidney DiseaseCancer (Radiotherapy/Chemotherapy)Artificial implantsUndiagnosed swelling or inflammation
Which area/s would you like treated:
I understand the nature of the procedure/s.

I confirm that all risks and benefits of the procedure/s have been explained to me and are fully understood by myself.

I acknowledge that I have been advised of the risks of this procedure/s.

I am aware that the proedure/s is not an exact science and that the results cannot be guaranteed.

No such guarantee has been given to me as to the results of this procedure/s.

I consent that I do not suffer from any of the contraidications listed for this procedure/s.

I certify that I am at least 18 years old or I have parental consent co-signed below.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I certify that that I have read, and fully understand the information given to me, and that I have had sufficient opportunity for discuession and to ask questions.

I consent to this procedure/s today and for all subsequent treatments.

I give my permission for my photos to be used as demonstration for results, ensuring patient confidentiality is maintained.
What you can expect:

Ø The suction pressure of a vacuum applicator may cause sensations of deep pulling, tugging and pinching. A surface applicator may cause sensations of pressure. You may experience intense cold, stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb.

Ø The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. These are all normal reactions that typically resolve within a few minutes.

Ø Bruising, swelling, and tenderness can occur in the treated area and it may appear red for one to two weeks after treatment.

Ø You may feel a dulling of sensation in the treated area that can last for several weeks after the procedure. Other changes – include swelling, itching, tingling, numbness, tenderness to the touch, pain in the treated area, cramping, aching, bruising and/or skin sensitivity – also have been reported.

Ø Patient experiences may vary. Some patients may experience a delayed onset of the previously mentioned symptoms. Contact us immediately if any unusual side effects occur or if symptoms worsen over time.

Ø You may start to see changes in as early as three weeks after your fat freezing treatment, and will experience the most dramatic results after one to three months. Your body will continue to naturally process the injured fat cells from your body for approximately four months after your procedure.

Ø Additional treatments may be needed to reach your desired outcome.

Ø In rare cases, patients have reported darker skin colour, hardness, discrete nodules, freeze burn, enlargement of the treated area, hernia or worsening of existing hernia following the fat freezing treatment. Surgical intervention may be required to correct tissue enlargement or hernia formation. I understand that these and other unknown side effects may also occur and will not hold Injex Clinics or any of its staff members liable.
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