Medical History Cryo Consent Form

Location*

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

DL #*

DL State of issue*

Date Of Birth*

Date

Height

Weight

Please List any Drug Allergies You Might Have

Please List any Medication You Currently Take

Have you had any previous surgeries or procedures?

Do you have any chronic medical conditions?

YesNo

How many hours a week do you exercise?

Initials*

What you can expect:
» The suction pressure may cause sensations of deep pulling, tugging and pinching. You may experience:
stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb.

The treated 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 all normal reactions that typically
resolve within minutes.

» Bruising, swelling, and 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/or soreness – also have been reported
after a ThermaSculpt treatment.

» Patient experiences will differ. Some patients may experience a delayed onset of the previously
mentioned occurrences.
Contact us immediately if any unusual side effects occur or if symptoms worsen over time.

» You may start to see changes as early as three weeks after ThermaSculpt, and you will experience the
most dramatic results after one to three months. Your body will continue naturally to process the
injured fat cells from your body for approximately four months after your procedure.

» You may decide that additional treatments are needed to reach your desired outcome.

» In rare cases, patients have experienced vasovagal symptoms during the treatment, and reported
freeze burn, darker skin color, hardness, discrete nodules or enlargement of the treatment area. Surgical
intervention may be required to correct the enlargement. I understand that these and other unknown
side effects may also occur.

Initials*

Cryoglobulinemia or paroxysmal cold hemoglobinuria*

YesNo

Known sensitivity to cold such as cold urticaria or Raynaud’s disease*

YesNo

Impaired peripheral circulation in the area to be treated*

YesNo

Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy*

YesNo

Impaired skin sensation*

YesNo

Open or infected wounds*

YesNo

Bleeding disorders or concomitant use of blood thinners*

YesNo

Recent surgery or scar tissue in the area to be treated*

YesNo

A hernia or history of hernia in the area to be treated*

YesNo

Skin conditions such as eczema, dermatitis, or rashes*

YesNo

Pregnancy or lactation*

YesNo

Any active implanted devices such as pacemakers and defibrillators*

YesNo

By purchasing products Receiving Treatment from NewYou Medical, you understand that results are not guaranteed, and individual outcomes may vary. You assume full responsibility for any risks, including potential side effects or interactions with other medications. NewYou Medical, is not liable for any adverse reactions or health issues that may arise from the use of these products.

All sales are final, and no refunds or returns will be accepted. By completing your purchase, you confirm your agreement to these terms and conditions.

Please Confirm*

I have read, understand and agree to the above statement

Date*

Date

Signature*

Medical History \ Cryo Consent Form

Medical History

Cryo-Therapy

Do you have of the following: