Cryoskin® Intake
Basic Information
Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Treatment History
Have you ever tried any other aesthetic procedures in the past?
Yes
No
If “yes”, which ones?
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
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Lifestyle Information
How many times per week do you exercise?
How much water do you drink per day?
How would you rate your diet?
Extremely healthy
Generally healthy
Needs improvement
Please circle your areas of concern:
Have any other treatments/diets/exercise regimens helped these areas?
What is your goal with Cryoskin?
Do you have any questions about Cryoskin?
Submit
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