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COSMED LASER SPA 

FREEZING FAT TREATMENT CONSENT FORM 

I do understand the cancellations and rescheduling policy and agree to pay the appropriate fees if I do not cancel or reschedule within 24 hours of my appointment date and time.

I do understand that taxes and gratuities are not included in any service I purchased. It is common practice to tip 15-20 % of the original service price. Please feel free to extend a gratuity as a result of your experience. Gratuities are accepted in the form of cash or credit card.

The Fat Freezing procedure uses a non-invasive vacuum applicator to draw in tissue and deliver controlled cooling at the surface of the skin. The procedure is for spot reduction of fat. It is not a weight-loss solution and it does not replace traditional methods such as liposuction. Someone who is overweight can expect to see less visible improvement than someone who has smaller fat deposits. Clinical studies have shown that Fat Freezing will naturally remove fat cells but, as with most procedures, visible results will vary from person to person. 


 

What you can expect:

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

➢  The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. You may feel a sense of nausea or dizziness as your body naturally warms and sensation returns to your treatment area. These are all normal reactions that typically resolve within minutes. 

➢  Bruising, swelling, and tenderness can occur in the treated area and it may appear red for a few hours after the applicator is removed. 

➢  You may feel a dulling of sensation in the treated area that can last for several weeks after your procedure. Other changes- including deep itching, tingling, numbness, tenderness to the touch, pain in the treated area, strong cramping, muscle spasms, aching and/or soreness- also have been reported after a Fat Freezing treatment. 

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

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

➢  You may decide that additional treatments are needed to reach your desired outcome. 
In rare cases, patients have reported hardness, discrete nodules or enlargement of the treatment area. I understand that these and other unknown side effects may also occur. 

➢ Bruises sometimes can slightly be burned and cause discoloration for few weeks.  


 

As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with Fat Freezing by Cosmed Laser Spa  and designated staff. 


 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Age Acknowledgment*
First Client's Date of Birth*
I certify that I am 18 years of age or older
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Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

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Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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Fifth Client's Name

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If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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Sixth Client's Name

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Yes

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What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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Seventh Client's Name

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What topical medications or creams are you currently using?
Retin-A

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What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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Yes

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What topical medications or creams are you currently using?
Retin-A

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FOR OUR FEMALE CLIENTS:


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Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
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First Name*

Last Name*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you ever used Accutane?*
No
Yes

If Yes, when did you last use it?
What topical medications or creams are you currently using?
Retin-A

Others (Please list):

FOR OUR FEMALE CLIENTS:


Occupation
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 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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