COOLTECH/COOL SHAPING INFORMED CONSENT FORM

Patient’s Name:
File No.:
DOB:
Mobile Number:
Visit Date:
Registration Time:
Doctor Name:

I understand that Cool Shaping is a proven procedure to reduce fat in target areas using the integrated technology by cryo, vacuum and LED; that it is a noninvasive cryo-cooling to reduce fat cells and breakdown the fat.

I confirm that I am not using any implanted medical/electrical devices; that I am not pregnant or breastfeeding; and that I have not undergone recent surgery.

I confirm that I do not suffer from the following conditions: any malignancy (cancer), seizure disorder or epilepsy, cardiac problems, diabetes, liver or kidney problems, high or low blood pressure, any infections, keloid scarring, (lymphatic blockage).

I confirm that I am not currently taking any anti-inflammatories, anti-coagulants or antibiotics.

I am aware that the treated area/s may develop temporary swelling, redness, mild bruising or hematoma, and/or discomfort.

I fully understand that the extent of fat loss cannot be guaranteed and will vary from one person to another. I am aware that failure to adhere to the aftercare procedure will have a negative impact on my final results.

I declare that I have had all aspects of the treatment fully explained to me. I have been given every opportunity to have my questions and concerns addressed adequately and I have been fully informed of any possible side effects.

I understand and agree that I am financially responsible for the payment I made for that any amount I paid for the sessions or procedures I booked it will only be valid up to 3 months from the date I made the payment. I understand that I need to utilize the sessions or procedures within 3 months period. I agree that my payment made is non-refundable or non-transferable post this period.

I declare that I have read and fully understood all points in this consent and that all of my questions were answered to my satisfaction and I take the full responsibility of my decision in this consent.

 

Patient Name & Signature :   

Doctor/Therapist Name & Signature :   

Witness Name & Signature :     

Parent or Gaurdian Name (if patient is minor) :

Date :

Consent to be photographed and published

I, , consent to be photographed and published on Social media, by while before and after the procedure. I further authorize that the photographs may be published for any purpose and in any form.

Patient Name & Signature :