Cryolipolysis  Consent Form
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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.

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