Coolsculpting® treatment consent form Preferred Location:*Please SelectLa Casita - 326 W. Craig PlaceSonterra - 18707 Hardy Oak BoulevardPatient Name: First Last What you can expect:* The CoolSculpting 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 CoolSculpting will naturally remove fat cells but, as with most procedures, visible results will vary from person to person. * 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 CoolSculpting 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 CoolSculpting, 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. Do you have any of the following?Cryoglobulinemia or paroxysmal cold hemoglobinuriaYesNoKnown sensitivity to cold such as cold urticaria or Raynaud's diseaseYesNoImpaired peripheral circulation in the area to be treatedYesNoNeuropathic disorders such as post-herpetic neuralgia or diabetic neuropathyYesNoImpaired skin sensationYesNoOpen or infected woundsYesNoBleeding disorders or concomitant use of blood thinnersYesNoRecent surgery or scar tissue in the area to be treatedYesNoA hernia or history of hernia in the area to be treatedYesNoSkin conditions such as eczema, dermatitis, or rashesYesNoPregnancy or lactationYesNoAny active implanted devices such as pacemakers and defibrillatorsYesNo* 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 the above information, and I give my consent to be treated with CoolSculpting by Dr. [insert physician name] and [his/her] designated staff.e-Signature :*Date This iframe contains the logic required to handle AJAX powered Gravity Forms.