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Consent For Fat Freeze
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
IC Num (Last 4 Digits)
About The Procedure
The Coolshaping 2 is a medical device KFDA Approved . The procedure utilizes high precision 360 cooling technology that can safely and effectively reduce and eliminate fat cells from specific areas of the body. Coolshaping2 can deliver significant fat layer reduction in these targeted areas which help to contour the body and reclaim its natural shape. This procedure is non-invasive with no anesthesia or recovery time. During the procedure tissue is drawn into a cup with vacuum pressure that may cause some discomfort or an unfamiliar sensation. Patients may also experience an uncomfortable cold sensation that typically subsides within 10-12 minutes after the procedure begins. If an excessively painful sensation is felt during the procedure please notify your therapist immediately. Once the procedure is complete, patients can immediately return to their normal activities, including work or exercise.
Please read the following statements carefully *
I understand that this procedure is cosmetic and is purely elective, that the results are not guaranteed and results may vary with each individual.
I understand that multiple treatments may be necessary.
I acknowledge that I am a competent, consenting adult of at least 18 years of age.
I consent to photographs for my record of the procedure area.
I understand that I have the right to consent or refuse any proposed procedure at any time prior to its performance
The suction pressure may cause sensation of deep pulling , tugging and pinching. You may experience intense stinging , tingling , aching or cramping as the treatment begins. These sensation generally subside as the area become numb .
The treatment 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 normal reaction that typically resolve within minutes
Bruising , swelling , 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 soreness also have been reported after a Coolshaping procedure treatment .
You may start to see changes as early as three weeks after Coolshaping . and you will experience the results after one to three months. Your body will continue naturally to proces the injured fat cells from your body for up to 4 months after your procedure .
Some of the rare complications / symptoms are frostbite, or first- and second-degree freeze burns. subcutaneous induration, a generalized hardness or specific hard nodules that develop in the treated area and can be painful
You may also have hyperpigmentation, or dark skin coloration that often resolves on its own
Do you have any of the following ? ( If ANY , you are NOT SUITABLE for this treatment )
Cryoglobulinemia or paroxysmal cold hemoglobinuria ?
Pregnant or breastfeeding ?
Known sensitivity to cold such as cold urticaria or Raynaud’s disease
Impaired peripheral circulation in the area to be treated ?
Neuropathic disorder such as post – herpetic neuralgia or diabetic neuropathy ?
Impaired Skin Sensataion
Paradoxical Adipose Hyperplasia (PAH ). This condition causes a gradual enlargement of the treated area. It occurs when the stimulus (the freezing of fat cells) activates a reactionary process in the fatty tissue that thickens and expands the fat cells rather than breaking them down and allowing the body to process and remove them.
Have a weakened immune system
Submission
By submitting this consent form, I confirm I have read this consent form and the consent form has been explained to me in terms which I understand. I understand the risks associated with this procedure and am aware there are alternative treatments available and would like to proceed with this treatment today. I understand this is not a medical procedure. Coolshaping2 by The Aesthetic Chapter is a cosmetic procedure and is not covered by any health insurance plan. I accept responsibility for all costs associated with this procedure and no refunds will be given .
Submit
Consent For Fat Freeze
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
IC Num (Last 4 Digits)
About The Procedure
The Coolshaping 2 is a medical device KFDA Approved . The procedure utilizes high precision 360 cooling technology that can safely and effectively reduce and eliminate fat cells from specific areas of the body. Coolshaping2 can deliver significant fat layer reduction in these targeted areas which help to contour the body and reclaim its natural shape. This procedure is non-invasive with no anesthesia or recovery time. During the procedure tissue is drawn into a cup with vacuum pressure that may cause some discomfort or an unfamiliar sensation. Patients may also experience an uncomfortable cold sensation that typically subsides within 10-12 minutes after the procedure begins. If an excessively painful sensation is felt during the procedure please notify your therapist immediately. Once the procedure is complete, patients can immediately return to their normal activities, including work or exercise.
Please read the following statements carefully *
I understand that this procedure is cosmetic and is purely elective, that the results are not guaranteed and results may vary with each individual.
I understand that multiple treatments may be necessary.
I acknowledge that I am a competent, consenting adult of at least 18 years of age.
I consent to photographs for my record of the procedure area.
I understand that I have the right to consent or refuse any proposed procedure at any time prior to its performance
The suction pressure may cause sensation of deep pulling , tugging and pinching. You may experience intense stinging , tingling , aching or cramping as the treatment begins. These sensation generally subside as the area become numb .
The treatment 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 normal reaction that typically resolve within minutes
Bruising , swelling , 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 soreness also have been reported after a Coolshaping procedure treatment .
You may start to see changes as early as three weeks after Coolshaping . and you will experience the results after one to three months. Your body will continue naturally to proces the injured fat cells from your body for up to 4 months after your procedure .
Some of the rare complications / symptoms are frostbite, or first- and second-degree freeze burns. subcutaneous induration, a generalized hardness or specific hard nodules that develop in the treated area and can be painful
You may also have hyperpigmentation, or dark skin coloration that often resolves on its own
Do you have any of the following ? ( If ANY , you are NOT SUITABLE for this treatment )
Cryoglobulinemia or paroxysmal cold hemoglobinuria ?
Pregnant or breastfeeding ?
Known sensitivity to cold such as cold urticaria or Raynaud's disease
Impaired peripheral circulation in the area to be treated ?
Neuropathic disorder such as post - herpetic neuralgia or diabetic neuropathy ?
Impaired Skin Sensataion
Paradoxical Adipose Hyperplasia (PAH ). This condition causes a gradual enlargement of the treated area. It occurs when the stimulus (the freezing of fat cells) activates a reactionary process in the fatty tissue that thickens and expands the fat cells rather than breaking them down and allowing the body to process and remove them.
Have a weakened immune system
Submission
By submitting this consent form, I confirm I have read this consent form and the consent form has been explained to me in terms which I understand. I understand the risks associated with this procedure and am aware there are alternative treatments available and would like to proceed with this treatment today. I understand this is not a medical procedure. Coolshaping2 by The Aesthetic Chapter is a cosmetic procedure and is not covered by any health insurance plan. I accept responsibility for all costs associated with this procedure and no refunds will be given .
Submit
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