COOL LIFTING C02 THERAPY FORM

Please fill out and submit the Consultation Form below which enables us to treat you.

* - Required Field.

First Name*
Last Name*
Are you 18 or over?*
Date of Birth*
Phone*
Email Address*
Address*
Postcode*
CONSENT FOR COOL LIFTING FACIAL

I understand the importance of withholding any medical conditions may be detrimental to my health and the outcome of the procedure.
I confirm that it is my responsibility to ask sufficient information about the treatment: *
PRECAUTIONS & CONTRAINDICATIONS

Due to the potential for an allergic reaction, is not recommended for clients with a history of severe allergies or a history of anaphylaxis, in particular wheat allergies.
Results: Your skin may feel tighter. This is an indication the treatment is working. Post treatment: Do not scratch, rub or stimulate the skin.
Leave the treatment to absorb into the skin for at least 2 hours before applying makeup.
It is advised to wear mineral make up. Leave the area to absorb product overnight and continue with your usual skincare regime the following day: *
ACKNOWLEDGMENT

I understand and acknowledge that payments for the above procedure are non-refundable and due at the time of service.
I further agree in the event of non-payment, to bear the cost of collection and/or Court cost and reasonable legal fees should this be required.
I certify that I have read and fully understand the content of this consent form for the procedure and that the disclosures referred to herein were made to me.
I release the therapist from liability associated with this procedure and all future procedures. I am not pregnant and I am not breastfeeding. I do not suffer from epilepsy.
I have not been diagnosed with medical oedema.
I am not undergoing chemotherapy or radiotherapy. Wait 2 weeks post Botox, Dermal Filler, Microblading, Micropigmentation treatments.
I understand and consent to photos for before and after comparisons.
I agree to follow all post treatment instructions carefully and understand that these guidelines are crucial for healing, prevention of side effects and complications. I wish to proceed with the treatment.
I understand that there are no guarantees as to the success of my treatment. I hereby give consent for a Cryosthetics trained specialist to carry out the treatment of my choice.
By accepting, I acknowledge that I have read the foregoing informed consent and agree to the treatment with its associated risks.
I hereby authorise Dolly Patel to administer such treatment to me and agree to hold her free from any claims, suits or damages for any injury or complications resulting from this treatment.
I confirm that I accept all liability: *
Sign Your Name*
Date*