CRYO CONSENT

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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I've had the following body sculpting treatments in the past: * This field is required.
Liposuction
CoolSculpting
EmSculpt
Sculptsure
Velashape
Vanquish
Zerona
LipoSonix
NeveSkin
N/A - None
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My current body mass index (BMI) is: * This field is required.Most people with a BMI of 35 or under, will qualify for treatment. CryoSliming is most effective with a BMI of 30 and under.
Please Select
Please Select
18.5 - 24.9
25 - 29.9
30 - 35
Over 36
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WHAT IS STAR T-SHOCK™ CRYOTHERAPY?

The PAGANI STAR T-SHOCK™ is an FDA approved cryotherapy device which uses thermal shock to safely and naturally firm laxity and reduce circumference without any damage to the skin. Cryotherapy also helps reduce the appearance of fine lines and wrinkles by stimulating collagen and elastin production while tightening muscles. This makes Star T-Shock beneficial for contouring of both the face and body.
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WHAT CRYO SERVICES DOES ECLAT OFFER?

CryoSculpting | CryoToning | CryoFacial

CRYO FACIAL

STAR T-SHOCK™ is the ONLY cryo facial which uses both warm and cold therapy to increase oxygen and nutrient supply to tissue, stimulating production of collagen and improving elasticity of skin and tightness of muscles. Cryo facials reduce the appearance of fine lines and wrinkles, under eye darkness and see brighter, smoother skin.

JAWLINE SCULPTING

Cryotherapy can be used to destroy stubborn fat while sculpting and toning your skin. You can finally achieve the jawline you have been dreaming about—without surgery or injectables—with STAR T-SHOCK™ double chin treatment. Learn how this non-invasive solution to under chin fat slims and tightens your neck and jawline for dramatic effects sans surgery.

CRYO 360 CONTOURING

Reduce circumference with this safe, quick, painless and effective treatment. No suction. No surgery. No down time. These 30 - 80 minute sessions minimize fat cells using controlled thermic shock technology. Just heat followed by cold. Sounds too good to be true? NeveSkin (formerly Cryoskin) treatments have an 89% satisfaction rating on RealSelf.com. See the results for yourself!

CRYO TONING & CELLULITE REDUCTION

Cellulite affects the majority of women, even athletes and fitness fanatics. When diet and exercise aren’t enough there’s Cryo Toning & Cellulite Reduction. STAR T-SHOCK™ increases circulation and boosts the production of collagen which breaks down cellulite, reducing the appearance of orange peel, improving elasticity and smoothing the skin.

CRYO PAIN RELIEF

Reduce pain, swelling and inflammation with our top of the line Cryo T-Shock device + red light therapy and percussive massage. We offer treatments for a range of issues:

Bursitis - Plantar fasciitis - Rotator Cuff - Tendonitis - Neck or Back pain
Sciatica - Muscle Recovery

ECLAT offers the most advanced cryo body contouring treatments in Cornelius, NC.
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IS STAR T-SHOCK™ CRYOTHERAPY SAFE FOR EVERYONE?

STAR T-SHOCK™ cryotherapy should not be performed under the following conditions:
• CryoSculpting should not be applied over inflamed, infected, swollen or sunburned areas of the skin.
• CryoSculpting should not be applied over/near cancerous areas or on clients with
active cancer or undergoing chemotherapy.
• CryoSculpting should not be used on clients who suffer from Kidney Disease and/or undergoing dialysis.
• CryoSculpting should not be used on clients who are pregnant.
• CryoSculpting treatments should not be applied over varicose veins.

• CryoFacial applications should not be used on clients who have had Botox
treatments within 14 days or Filler treatments within 30 days.
• CryoSculpting abdominal or flank treatments should not be used on clients with open
abdominal hernias.
• CryoSculpting should not be used on clients who suffer from severe diabetes or where sensation has been lost in the skin.
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CRYOSCULPTING CONTRAINDICATIONS: Please check any health condition which applies to you:* This field is required.
Severe Raynaud's
Severe reaction to cold
Progressive Disease (Neuropathy, MS)
Active Cancer
Lymphatic disorder
Varicose Vein / Hernia
Uncontrolled Diabetes
Severe Kidney or Liver Disease
Pregnant / Breastfeeding
Bacterial /viral infection
Circulatory disorder
Surgery in the past 6 months
Pacemaker / metal implants
Eczema / Rashes
Silicone / implants in treatment area
Mesh inserts in treatment area
Body piercings in treatment area
NONE
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CRYO FACIAL CONTRAINDICATIONS: Please check any health condition which applies to you:* This field is required.
Botox in the last 2 weeks
Filler in the last 30 days
Chemical Peel in the last 2 weeks
Severe Raynaud's
Circulatory disorder
Severe reaction to cold
Progressive Disease (Neuropathy, MS)
Eczema / Rashes / Dermatitis
Grade 2-3 Acne
Sunburn
Silicone / Metal facial implants
Mesh inserts in treatment area
Piercings in treatment area
Topical antibiotics in the treatment area
Facial surgery in the last 6 months
NONE
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Are you currently using, or previously used any injectable semaglutide or tirzepatide medications? (Ozempic, Mounjaro, Wegovy, Rybelsus etc)* This field is required.**Use of these weight loss injections causes skin changes and inflammation which may increase chances of side effects from some aesthetic treatments. Please always notify your provider when you are using these medications. **
YESNO
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I'm interested in learning more about the following STAR T-SHOCK offers:(Select all that apply)
STAR T-SHOCK Facials
STAR T-SHOCK Double Chin Tuck
STAR T-SHOCK Slimming
STAR T-SHOCK Toning
STAR T-SHOCK Cellulite
STAR T-SHOCK Pain Relief
STAR T-SHOCK Hand Rejuvenation
STAR T-SHOCK Packages
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By engaging ECLAT Skin Confidence Spa ("Company") to perform Star T-Shock cryotherapy treatments ("Services"), I hereby acknowledge there are certain inherent risks and dangers associated with the Service. At all times I shall comply with stated terms, safety rules and verbal instructions given to me by staff. I choose to voluntarily request the Services by performed on me. * This field is required.TOGGLE "YES" TO ACCEPT
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I understand my participation in the services will expose me to extremely cold temperatures. Should any pain or discomfort occur, I will immediately notify the technician. I understand I must be age 16 or older to receive cryotherapy.* This field is required.TOGGLE "YES" TO ACCEPT
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I understand results may vary depending on individual factors including but not limited to medical history, prior treatments in the area, skin type, medications, hormone levels, hormone imbalance, insulin resistance, lifestyle and patient compliance with pre/post session instructions. I understand I must maintain good dietary habits, have sufficient water intake, engage in light physical activity and adhere to recommended session intervals.* This field is required.TOGGLE "YES" TO ACCEPT
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I understand that by participating in a Case Study, I may be photographed or videoed by the Company for marketing, treatment monitoring and training purposes. If pictures are used for training or marketing purposes, all identifying marks and faces will be cropped out, unless the treatment is done on the face. I hereby consent to such usage of my imagery by the Company without restriction.* This field is required.TOGGLE "YES" TO ACCEPT
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I hereby (1) agree to assume full responsibility for any injuries which are sustained or aggravated by me in relation to my receiving of the Service, (2) release, indemnify and hold harmless the Company, its agents and employees from any claims or suits related to the Services, and (3) represent that I have no medical or physical condition that prohibits me from receiving the Services. I further understand the Company is not a medical provide; if I'm unsure about safety for any reason, I hereby acknowledge the Company's recommendation that I consult a medical physician before receiving Services.* This field is required.TOGGLE "YES" TO ACCEPT
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CryoSculpting Before and After Instructions* This field is required.REVIEW AND CHECK ALL TO CONFIRM
DO NOT exercise BEFORE the treatment as it makes it more difficult for the body to cool
DO exercise AFTER the treatment vigorously 30 minutes to improve lymphatic drainage
AVOID eating sugar & carbohydrates 4-5 hours before & after your cryo session
WAIT 72 hours after cryosculpting or toning to use a sauna or tanning bed
BOOST your results by drinking water, getting lymphatic massage or dry brushing
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Cryo T-Shock experts are available for consultation Tuesday through Saturday. Which day do you prefer?
Please Select
Please Select
Tuesdays
Wednesdays
Thursdays
Fridays
Saturdays
Saturday PM
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Please provide an email so we can send you instructions on next steps in scheduling your professional consultation. Thank you!
example@example.com
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SIGNATURE: I have read this Assumption of Risk, Waiver and Release, fully understand its terms and am aware I am giving up rights to sue the Company under certain circumstances. I am signing this waiver freely and voluntarily. The term of this waiver is indefinite. * This field is required.
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Please provide a phone number if you wish to be contact
Please enter a valid phone number.
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