CONSENT FORM – CRYOLIPOLYSIS

I have had a consultation either by way of an on-line or in-person presentation, in which I have been advised of the benefits and potential side effects of cryolipolysis and I consent to receiving treatment.

I UNDERSTAND THAT IN RELATION TO CRYOLIPOLYSIS:

– Cryolipolysis, whilst permanent, is variable and results may vary. Most clients require 3 treatments per treated area.

– The treatment is most successful with clients maintaining healthy eating and regular exercise. The procedure is for spot reduction of fat and is not a weight loss solution.

– Regardless of precautions taken, I acknowledge that adverse effects may occur.

I UNDERSTAND THE FOLLOWING COMMON SIDE EFFECTS ASSOCIATED WITH CRYOLIPOLYSIS:

– In the days following treatment, the area may ache and feel bruised. This aching, as well as redness, bruising, swelling, tenderness, itching, skin sensitivity and tingling can last 1-2 weeks. The skin may feel numb; this reduction in sensation can last several weeks, but gradually resolves.

– For 1 in 20 people there is a strong cramping or muscle spasm or a shooting pain that occurs up to 2 weeks after treatment. Generally, this is tolerated without pain relief; however, you may use compression garments and cool packs in the evening if required.

– You may start to see changes as early as 3 weeks after treatment, but optimal results are achieved after 1-2 months. Your body continues to remove the damaged fat cells for up to 4 months after your procedure.

– After 4 weeks, you may decide if you require additional treatments to reach your desired outcome.

– Eating healthily is required in the weeks leading up to your treatment, to optimise the results.

I UNDERSTAND THE FOLLOWING RARE SIDE EFFECTS ASSOCIATED WITH CRYOLIPOLYSIS:

– Late onset pain several days after treatment, and resolution within several weeks

– Vasovagal symptoms: dizziness, light-headedness, nausea, flushing, sweating or fainting during or immediately after the treatment

– Subcutaneous induration: generalised hardness and/or discrete nodules within the treatment area which may develop after the treatment, and may present with pain and/or discomfort.

– Hyperpigmentation may occur after treatment. Typically, it resolves spontaneously.

– Hernia: treatment may cause new hernia formation or exacerbate pre-existing hernia, which may require surgical repair.

-Paradoxical hyperplasia: visibly enlarged volume within the treatment area, which may develop 2-5 months after treatment. Surgical intervention may be required.

IN RELATION TO MY INITIAL AND ALL SUBSEQUENT TREATMENTS, I ADVISE THAT:

– I do not suffer from cryoglobulinaemia.

– I do not suffer from paroxysmal cold haemoglobinuria.

– I do not suffer from sensitivity to cold such as yaynaud’s disease or cold urticarial.

– I do not suffer from Neuropathic disorders such as posthepatic neuralgia or diabetic neuropathy.

– I do not suffer from impaired skin sensation.

If I pre-pay for treatments, I will save an amount according to the pre-payment schedule. I am aware that there is no refund on pre-pays and that they are not transferable to other individuals, treatments or clinics and that pre-pays have a 6-month expiry date (less than 5 treatments) or an 18-month expiry date (5 or more treatments). I am further aware that 72 hours notice is required for any appointment cancellations. If I cancel within 72 hours or do not attend an appointment, a cancellation fee of 50% of the treatment cost will apply. In the case of prepaid treatments, the treatment will be forfeited. I have read all the material provided and have had all my questions satisfactorily answered. No representations have been made in relation to the effectiveness of the treatment.

I have obtained or have elected at my own risk not to obtain the advice of an independent medical practitioner in relation to this treatment in respect of any possible adverse health risks. I consent to undergoing the treatment at my own risk.

CONSENT FORM – WHOLE BODY CRYOTHERAPY

I have had a consultation either by way of an on-line or in-person presentation, in which I have been advised of the benefits and potential side effects of whole body cryotherapy and I consent to receiving treatment.

I UNDERSTAND THAT IN RELATION TO WHOLE BODY CRYOTHERAPY:

– I must wear dry cotton or wool socks, dry cotton or wool gloves, and dry underwear, to avoid frostbite. – I must wear protective shoes/clogs.

– Treatments are limited to three (3) minutes per session.

– Overexposure to the cold temperatures may cause frostbite;

– During treatment, I must avoid inhaling the nitrogen fumes; while non-toxic, they are devoid of oxygen and may cause fainting or in certain circumstances even death.

– I must ensure my head is lifted a minimum of 15cm above the edge of the cryosauna so I can breathe the air from the room and not the mixture of gases from the cryosauna.

– I must have dry skin without recent application of lotions and moisturizers.

– I may end the procedure at any time if you experience any problems or anxiety.

– Abnormal skin sensitivity to cold may be caused by certain foods, cosmetics, or medication, including but not limited to the following: tranquilizers, high blood pressure medication.

– A person who is less than eighteen (18) years of age must not use whole body cryotherapy without parental or guardian consent.

– I must not wear any jewellery during your treatment.

– I must be in visual contact with the operating staff during the entire treatment procedure.

– I must follow all instructions on the use of the cryosauna during your treatment.

– I should not use whole body cryotherapy if I have any of the following: pregnancy, hypertension (BP> 180/100), acute or recent myocardial infarction, unstable angina pectoris, arrhythmia, symptomatic cardiovascular disease, cardiac pacemaker, peripheral arterial occlusive disease, asthma, venous thrombosis, acute or recent cerebrovascular accident, uncontrolled seizures, Raynaud’s Syndrome, fever, tumor disease, symptomatic lung disorders, bleeding disorders, severe anemia, infection, claustrophobia, cold allergy, acute kidney and urinary tract diseases.

– Fluctuations in blood pressure may occur (due to peripheral vasoconstriction, blood pressure may briefly increase by up to 10 points systolically during treatment). This effect should dissipate upon completion of the procedure, as peripheral circulation returns to normal).

– I may experience an allergic reaction to the extreme cold (rare), claustrophobia, anxiety, temporary redness of the skin, or chilblains (rare).

– Eating healthily is required in the weeks leading up to your treatment, to optimise the results.

Regardless of precautions taken, I acknowledge the possibility of an adverse reaction and accept sole responsibility for any medical care that may become necessary.

If I pre-pay for treatments, I will save an amount according to the pre-payment schedule. I am aware that there is no refund on pre-pays and that they are not transferable to other individuals, treatments or clinics and that pre-pays have a 6-month expiry date (less than 5 treatments) or an 18-month expiry date (5 or more treatments). I am further aware that 72 hours notice is required for any appointment cancellations. If I cancel within 72 hours or do not attend an appointment, a cancellation fee of 50% of the treatment cost will apply. In the case of prepaid treatments, the treatment will be forfeited. I have read all the material provided and have had all my questions satisfactorily answered. No representations have been made in relation to the effectiveness of the treatment.

I have obtained or have elected at my own risk not to obtain the advice of an independent medical practitioner in relation to this treatment in respect of any possible adverse health risks. I consent to undergoing the treatment at my own risk.

RELEASE AND INDEMNITY

In consideration of CA or any of its affiliates, or franchisees (collectively referred to as the CA Group), providing me with whole body cryotherapy treatments, and for other good and valuable consideration, the receipt and sufficiency of which is acknowledged, I hereby agree to:

(a) waive any and all claims that I have or may have in the future against the CA Group and their owners, therapists, doctors, nurses, volunteers, directors, officers, employees, and independent contractors, (hereinafter referred to as the “Releasees”) and to release the Releasees from any and all liability for any loss, damage, expense or injury including death that I may suffer, due to any cause whatsoever, including negligence, breach of contract, or breach of any statutory or other duty of care, on the part of the Releasees, and including the failure on the part of the Releasees to safeguard or protect me from any risks associated with the administration of the treatments;

(b) hold harmless and indemnify the Releasees from any and all liability for any property damage or personal injury to any third party resulting directly or indirectly from treatments I have received from the CA Group; and

(c) hold harmless and indemnify the Releasees from any and all liability, losses, claims or costs I suffer which are caused or contributed to by, and resulting from, directly or indirectly, any act or omission of the Releasees.

CONSENT FORM – Acoustic Radio Wave Therapy (ANTI-CELLULITE TREATMENT)

I have had a consultation in which I have been advised of the benefits of ARWT Anti-Cellulite Treatment and I consent to receiving treatment

I UNDERSTAND THAT IN RELATION TO ARWT ANTI-CELLULITE TREATMENT:

– The device creates acoustic mechanical waves which are activated on the cellulite area, increasing collagen and elastin synthesis in the walls supporting the fat cells that protrude to the skin surface in cellulite. In addition, this treatment reduces the concentration of toxins in the surroundings of the fat cells.

– Prior to treatment I will undergo a physical examination that will document cellulite level as follows:

  1. Skin on the thigh, pelvis or buttocks area will be held between the thumb and the index finger. If the skin of this area will assume wavy, dimpled or “orange peel” appearance – this is cellulite. Usually the cellulite area has a paler shade and it’s cooler in comparison to other skin areas of the body. The cellulite area skin is softer under pressure of massage. People with cellulite might feel as though the cellulite area is “heavier”.
  2. During the physical examination, the severity level of cellulite on my body parts will be assessed and documented.– Expected Duration (Treatment & Follow-Up): I am about to undergo a series of 13-26 treatment sessions of approximately 10 minutes per treatment area, dependent on assessment of cellulite level. Treatment will be conducted in sequential weeks – twice a week and followed by maintenance treatment of once monthly.

– Treatment evaluation will include:

  1. Full physical evaluation of the cellulite area(s). All findings will be documented in client notes.
  2. The area dedicated to treatment will be photographed prior to the initiation of treatment program, and at the completion of treatment program, 1 month following treatment completion, and 3 months following treatment completion.
  3. The circumference of the treated area will be measured prior to initiation of the treatment program, and at the completion of treatment program as well as 1 month following treatment completion, and 3 months following treatment completion.
  4. Expected Benefit: Based on similar treatments conducted in people with a similar problem to mine, I expect to have a certain temporary improvement expressed by decreased circumference in the area treated for cellulite in comparison to pre-treatment measurements, decrease in cellulite severity level as detailed above, visible improvement in photographs taken after treatment program completion in comparison to photos taken prior to treatment initiation.
  5. Adverse Events: There are no known adverse reactions to this treatment. Nevertheless, should they occur they are expected to be mild such as a local temporary bruising lasting for several days. Should any adverse events occur, I’ll report them to Cryoclinics Australia (CA).
  6. Potential Risks: I am aware of the fact that acoustic radial wave treatment for a variety of applications such as orthopaedic pathologies has been accepted for years. Low energy acoustic radial wave treatment is easy to conduct, non-invasive, with no apparent adverse events and has short treatment series duration.
  7. I am aware of the fact that the beneficial effect of with acoustic radial waves treatment requires maintenance treatment once monthly.
  8. Regardless of precautions taken, I acknowledge the possibility of an adverse reaction and accept sole responsibility for any medical care that may become necessary.

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