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This Consultation Form is for any treatment done using the Cryoskin machine, including but not limited to CryoSlimming®, CryoToning®, and the CryoFacial. 

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Have you ever tried any other aesthetic procedures in the past?*
No
Yes

If "yes", which ones?
How did you hear about Cryoskin?*
Friend/Family
TV/Radio
Internet
Other

If "other", please specify.
Background Information (please check all that apply) *
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Kidney and/or Liver disease
Lymphatic disorders
Severe allergy to cold
Eczema, rashes, or dermatitis
Circulatory disorders
Mesh inserts
HIV/AIDS
Using topical antibiotics
Cold-related Illness
Bacterial/viral skin infection
Impaired skin sensation
Hernia in desired treatment area
Impaired mental status
Fillers in the past 90 days
Implants in desired treatment area
Active/Past Cancer
Cardiovascular Disease
Uncontrolled Diabetes
Severe Raynaud's Syndrome
Open or infected wounds
Pacemaker/implanted electrical devices
Incision scar(s) in the desired area
Body piercings in the desired area
Lower Limb Ischemia
Progressive diseases (MS, ALS, etc.)
Wound healing disorders
Known sensitivity to propylene glycol
Current/recent bleeding or hemorrhage
Regenerating nerves
None of the above

How many times per week do you exercise? *

How much water do you drink per day? *
How would you rate your diet?*
Extremely healthy
Generally healthy
Needs improvement

Please list your areas of concern on your body. *

Have any other treatments/diets/exercise regimens helped these areas? *

What is your goal with Cryoskin? *
Do you have any questions about Cryoskin?*
No
Yes

If "yes", please write your questions here.
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.


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