Loading...

This consent form is designed to verify that you have been satisfactorily informed and educated in respect to your fat reduction treatment, as well as its aftercare, so that you may make an educated decision as to whether or not to have this procedure performed. Please read and initial each paragraph below.  Feel free to ask us any questions you may have.  

GENERAL INFORMATION: 

 Prior to receiving this treatment, I have been candid in revealing any condition that may have a bearing on this procedure, such as pregnancy, breast feeding, Cryoglobulinemia (a condition in which an abnormal level of proteins thicken the blood in cold temperature), paroxysmal cold hemoglobinuria or cold agglutinin disease (blood disorders in which cold temperatures lead to red blood cell death), known sensitivity to cold such as cold urticarial (hives triggered by cold) or Raynaud’s disease (disorder in which cold leads to reduced blood flow in the fingers, which appear white, red, or blue), pernio or Chillblains (itchy and/or tender red or purple bumps that occur as a reaction to cold), impaired peripheral circulation, poor blood flow in area to be treated, Diastatis Recti, neuropathic (nerve) disorders such as post-herpetic neuralgia or diabetic neuropathy, impaired skin sensation, open or infected wounds, bleeding disorders or use of blood thinners, recent surgery or scar tissue in area to be treated, hernia or history of hernia in the area to be treated or adjacent to treatment site, any major health problems such as liver disease, any known sensitivity to isopropyl alcohol or propylene glycol, any skin conditions such as eczema, dermatitis or rashes, or active implanted devices such as pacemakers and defibrillators.  

 

I understand that this procedure uses a non-invasive thermoelectric cooling technology to freeze and kill subcutaneous fat tissue. The procedure is for spot reduction of fat. It is not a weight-loss solution and it does not replace traditional methods such as diet, exercise or liposuction. Someone who is overweight can expect to see less visible improvement than someone who has smaller fat deposits. Following the procedure, the treated fat cells are naturally processed by the body. As with most procedures, visible results will vary from person to person.  

 

 The thermoelectric cooling technology 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.  

 

 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, lightheadedness, flushing, sweating, fainting 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, redness, cramping, tenderness and pain can occur in the treated area and it may appear red or discolored for a period of weeks after treatment.  

 

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

 

 After submental area treatment, a feeling of fullness in the back of the throat may occur.

 

 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.  

 

Results continue 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.  

 

 Results vary from person to person. You may decide that additional treatments are needed to reach your desired outcome. Although highly unlikely, it is possible that you will not experience any noticeable results from the procedures. 

 

  I understand this procedure will be conducted by a trained Technician, PA or NP.

RISKS/SIDE EFFECTS: 
 

A small number of patients have experienced gradual development of a firmer enlargement, of varying size and shape, of the treatment area, known as “paradoxical hyperplasia”, in the months following the treatment. If such paradoxical hyperplasia occurs, it will be distinguishable from temporary swelling and will probably not resolve on its own. The enlargement/lump can be removed by means of a surgical procedure such as liposuction.  

 

  A small number of patients have experienced excessive fat removal in the treatment area, resulting in an unwanted indentation (treatment area demarcation). The indentation may be improved through corrective procedures.  

 

 In rare cases, patients have experienced vasovagal symptoms during the treatment, and reported frostbite, darker skin color, hardness or discrete nodules. Treatment may cause new hernia formation or exacerbate pre-existing hernia, which may require surgical repair. I understand that these and other unknown side effects may also occur.  

 

With full knowledge and understanding of the risks/hazards discussed above, I voluntarily request the procedure be performed. I have been informed of the nature, risks, and possible complications and consequences of these procedures. I fully understand this is a process and therefore not an exact science and that all clients have different experiences and outcomes due to their unique body composition. I accept full responsibility for the decision to have this body work performed on me and I accept the possible consequences of said procedure.  

 

 I understand that although complications are rare, sometimes they may occur and that attention may be necessary. In the event of any complication, I will immediately contact the center.  If I think it's a medical emergency, I will call the doctor, go to the emergency department, or call 911 immediately.

 

 I understand that these and other unknown side effects may also occur. 

AUTHORIZATION AND WAIVER  

 

 I hereby authorize The Cryotherapy Place dba CryoPlace, its employees, and agents to perform the fat reduction procedure on me. I fully understand that this procedure has limited applications. I am aware that the practice of aesthetics is not an exact science and I acknowledge that my aesthetician cannot guarantee quality and/or results or freedom from complications. I acknowledge that I have had the opportunity to ask questions, and that I fully understand the procedure.  

 

I understand and acknowledge that there are risks involved with the fat reduction procedure, including but not limited to those side effects listed above. I have had the opportunity to ask questions regarding these risks and other possible complications. I understand that any false or misleading information I have given may lead to undesired results and complications and hereby release and hold harmless The Cryotherapy Place from any and all liability if such results or complications occur. I further understand that my failure to follow post care instructions may also lead to undesired results, complications or effects and hereby release and hold harmless The Cryotherapy Place from liability if such results or complications occur.  

 

 “Before” and “After” photos are required for all  treatments.  

 

 Any payment made for treatments is non-refundable. Any unused treatments will be available as an in-house credit on your account, and can be used to purchase treatments or products.  

 The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment.

In exchange for participation in activity organized by The Cryotherapy Place, LLC, of 1039 Grant St. SE #A21A, Atlanta, Georgia 30315 and/or use of the property, facilities and services of Cryogen Plus LLC, I agree for myself and (if applicable) for the members of my family, heirs, executors or guardians, to the following:

1. AGREEMENT TO FOLLOW DIRECTIONS. I agree to observe and obey all posted rules and warnings, and further agree to follow any oral instructions or directions given by The Cryotherapy Place, LLC, or the employees, representatives or agents of The Cryotherapy Place, LLC.  

2. ASSUMPTION OF THE RISKS AND RELEASE. I recognize that there are certain inherent risks associated with the above described activity and I assume full responsibility for personal injury to myself and (if applicable) my family members, heirs, executors or guardians and further release and discharge The Cryotherapy Place, LLC for injury, loss or damage arising out of my or my heirs, executors or guardians use of or presence upon the facilities of The Cryotherapy Place, LLC, whether caused by the fault of myself, my family, heirs, executors or guardians or other third parties.

3. INDEMNIFICATION. I agree to indemnify and defend The Cryotherapy Place, LLC against all claims, causes of action, damages, judgments, costs or expenses, including attorney fees and other litigation costs, which may in any way arise from my or my family heirs, executors or guardians of or presence upon the facilities of The Cryotherapy Place, LLC.

4. FEES. I agree to pay for all damages to the facilities of The Cryotherapy Place, LLC caused by any negligent, reckless, or willful actions by me or my family, heirs, executors or guardians.

5. APPLICABLE LAW. Any legal or equitable claim that may arise from participation in the above shall be resolved under Georgia law.

6. NO DURESS. I agree and acknowledge that I am under no pressure or duress to sign this Agreement and that I have been given a reasonable opportunity to review it before signing. I further agree and acknowledge that I am free to have my own legal counsel review this Agreement if I so desire. I further agree and acknowledge that The Cryotherapy Place, LLC has offered to refund any fees I have paid to use its facilities if I choose not to sign this Agreement.

7. ARM'S LENGTH AGREEMENT. This Agreement and each of its terms are the product of an arm's length negotiation between the Parties. In the event any ambiguity is found to exist in the interpretation of this Agreement, or any of its provisions, the Parties, and each of them, explicitly reject the application of any legal or equitable rule of interpretation which would lead to a construction either "for" or "against" a particular party based upon their status as the drafter of a specific term, language, or provision giving rise to such ambiguity.

8. ENFORCEABILITY. The invalidity or unenforceability of any provision of this Agreement, whether standing alone or as applied to a particular occurrence or circumstance, shall not affect the validity or enforceability of any other provision of this Agreement or of any other applications of such provision, as the case may be, and such invalid or unenforceable provision shall be deemed not to be a part of this Agreement.

9. DISPUTE RESOLUTION. The parties will attempt to resolve any dispute arising out of or relating to this Agreement through friendly negotiations amongst the parties. If the matter is not resolved by negotiation, the parties will resolve the dispute using the below Alternative Dispute Resolution (ADR) procedure.

Any controversies or disputes arising out of or relating to this Agreement will be submitted to mediation in accordance with any statutory rules of mediation. If mediation is not successful in resolving the entire dispute or is unavailable, any outstanding issues will be submitted to final and binding arbitration under the rules of the American Arbitration Association. The arbitrator's award will be final, and judgment may be entered upon it by any court having proper jurisdiction.

 I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to the procedure described above.  

I HAVE READ THIS DOCUMENT AND UNDERSTAND IT. I FURTHER UNDERSTAND THAT BY ACCEPTING THIS RELEASE, I VOLUNTARILY SURRENDER CERTAIN LEGAL RIGHTS.

First Client Name

First Name*

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
Second Client Name

First Name*

Last Name*
Second Client Date of Birth*
Third Client Name

First Name*

Last Name*
Third Client Date of Birth*
Fourth Client Name

First Name*

Last Name*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Last Name*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Last Name*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Last Name*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Last Name*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Last Name*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Last Name*
Tenth Client Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!