Intake Form
Name
First Name
Surname
DOB
1. Have you ever tried any other aesthetic procedures in the past?
Yes
No
2. If "yes", which ones?
3. How did you hear about Cryoskin?
Friend/Family
TV/Radio
Internet
Other
Background Information (please check all that apply)
Botox in the past 30 days
Fillers in the past 90 days
Surgery in the past 6 months
Implants in desired treatment area
Pregnant and/or breastfeeding
Active/Past Cancer
Kidney and/or Liver disease
Cardiovascular Disease
Lymphatic disorders
Uncontrolled Diabetes
Severe allergy to cold
Severe Raynaud's Syndrome
Eczema, rashes, or dermatitis
Open or infected wounds
Circulatory disorders
Pacemaker/metal implants
Mesh inserts
Incision scar(s) in the desired area
HIV/AIDS
Body piercings in the desired area
Using topical antibiotics
Lower Limb Ischemia
Cold-related Illness
Progressive diseases MS, ALS, etc
Bacterial/viral skin infection
Wound healing disorders
Impaired skin sensation
Known sensitivity to propylene glycol
Hernia in desired treatment area
CRYOS
1. How many times per week do you exercise?
2. How much water do you drink per day?
3. How would you rate your diet?
Extremely healthy
Generally healthy
Needs improvement
4. Please list your areas of concern
5. Have any other treatments/diets/exercise regimens helped these areas improve?
6. What is your goal with Cryoskin?
7. Do you have any questions about Cryoskin?
Photo Consent: Pictures will be obtained for records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed, unless the treatment is done on the face.
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