Cryolipolysis Consent Form

    Explanation of Cryolipolysis (Fat Freezing) Procedure:

    The Cryolipolysis procedure utilises highly controlled cooling technology that can safely and effectively
    reduce and eliminate fat cells from specific areas of the body. Cryolipolysis can deliver significant fat
    layer reduction in these targeted areas which help to contour the body and reclaim its natural shape. This
    procedure is non-invasive with no anesthesia or recovery time. During the procedure tissue is drawn into
    a cup with mild vacuum pressure that may cause some discomfort or an unfamiliar sensation. Patients
    may also experience an uncomfortable cold sensation that typically subsides within 10-12 minutes after
    the procedure begins. If an excessively painful sensation is felt during the procedure please notify your
    technician immediately. Once the procedure is complete, patients can immediately return to their normal
    activities, including work or exercise.

    Contraindications of the Cryolipolysis (Fat Freezing) procedure may include, but are not limited to:

  • Cryoglobulinemia
  • Paroxysmal cold hemoglobinuria
  • Cold urticarial
  • Areas of impaired peripheral circulation
  • Raynaud's disease or Raynaud's phenomenon
  • Severe diabetes
  • Liver Problems
  • Thin, frail skin
  • Please read the following statements carefully and acknowledge all:

    I understand that this procedure is cosmetic and is purely elective, that the results are not guaranteed and results may vary with each individual.
    I understand that multiple treatments may be necessary.
    I acknowledge that I am a competent, consenting adult of at least 18 years of age.
    I consent to photographs for my medical record of the procedure area and for marketing purposes.
    I understand all post-procedure recommendations and agree to adhere to them.
    I understand that there may be some pain, cramping and swelling post treatment that may last 2-3 weeks.
    I understand there may be bruising, redness and numbness to the area being treated post treatment that may last 2-3 weeks or more.
    I will notify Body Contour Studio if the pain is severe or lasts longer than explained to me.
    I understand that I have the right to consent or refuse any proposed procedure at any time prior to its performance.
    I understand I must notify the clinician if my medical history changes prior to subsequent treatments.

    Do you have any of the following? (Tick where applicable)

    Cryoglobulinemia or paroxysmal cold hemoglobinuria.
    Known sensitivity to cold such as cold urticaria or Raynaud’s disease.
    Impaired peripheral circulation in the area to be treated.
    Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy.
    Impaired Skin sensation.
    Open or infected wounds.
    Bleeding disorders or concomitant use of blood thinners.
    Recent surgery or scar tissue in the area to be treated.
    A hernia or history of hernia in the area to be treated.
    Skin conditions such as eczema, dermatitis, or rashes.
    Pregnancy or lactation.
    Any active implanted devices such as pacemakers and defibrillators.
    Cancer.
    Epilepsy.
    Seizures.
    Lupus.
    Thrombosis.
    Phlebitis.
    Hemophili.
    HIV or AIDS.
    Cardiac Problems.
    Multiple Sclerosis.
    Metal Implants/Screws.
    Hormonal Disorders.
    Hypoglycemia.
    Asthma or any respiratory conditions.
    Thyroid Disorders.
    Muscular Conditions.
    High or Low Blood Pressure.



    Release

    I recognise that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Body Contour Studio (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself, Body Contour Studio or other third parties, or in any way arising out of the above described treatment I have requested Body Contour Studio perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Body Contour Studio including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under New South Wales (NSW) law. I agree to indemnify, hold harmless and defend Body Contour Studio (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including lawyers’ fees and other litigation costs, which may in any way arise from the above described treatment I have requested Body Contour Studio perform.

    Arbitration

    It is understood that any dispute arising as to malpractice of the Cryolipolysis (Fat Freezing) treatment shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by New South Wales (NSW) arbitration act, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own lawyers’ fees and costs. Any action to collect fees from the client/patient for the treatments performed may be brought in any court located in New South Wales (NSW) and the prevailing party in such collection action shall be entitled to recover its reasonable lawyers’ fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim.

    By signing this agreement (consent form), I confirm that I am over the age of 18, I understand that the Cryolipolysis (Fat Freezing) procedure stimulates permanent changes, that such procedure has possible adverse consequences and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs, fully understand this consent and procedure form and hereby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the Cryolipolysis (Fat Freezing) procedure which is to be performed at my request according to this agreement. I further understand that by signing this agreement, I surrender certain legal rights.