Cryolipolysis Consent Form
How did you hear about us?
Post Cards In Mail
Referred by a friend Great! What is there name?
We Will Give Them $5 Off There Next Service
Do you have any of the following?
Cryoglobulinemia or paroxysmal cold hemoglobinuria
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated
Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy
Impaired skin sensation
Open or infected wounds
Bleeding disorders or concomitant use of blood thinners
Recent surgery or scar tissue in the area to be treated
A hernia or history of hernia in the area to be treated
Skin conditions such as eczema, dermatitis, or rashes
Pregnancy or lactation
Any active implanted devices such as pacemakers and defibrillators
Pictures will be obtained for medical records.
If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed.
As with most medical procedures, there are risks and side effects. These have been explained to me in detail.
I have read and understood the above statements and agree to use the Ion Cleanse within the stated guidelines. I release the Ion Cleanse technician and Aroma Wellness Clinic and Spa from any responsibility associated with my health during or after the session.