Cryoskin Consultation Form Full Name Email Date of Birth (YYYY-MM-DD) How did you hear about Cryoskin? Friend/Family Facebook Instagram TV/Radio Internet Other Have you ever tried any other aesthetic procedures in the past? Yes No IF YES...what have you tried. BACKGROUND INFORMATION (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 or Breastfeeding Kidney and/or Liver disease Lymphatic disorders Active Cancer Past Cancer Cardiovascular disease Uncontrolled diabetes Severe Raynaud's Syndrome Severe allergy to cold Eczema, rashes, or dermatitis Circulatory disorders Mesh inserts Pacemaker / metal implants HIV/AIDS Open or infected wounds Wound healing disorders Using topical antibiotics Cold-related illness Bacterial / Viral skin infection Impaired skin sensation Hernia in desired treatment area Incision scar(s) in desired treatment area Body piercing(s) in desired treatment area Lower Limb Ischemia Progressive Diseases (MS, ALS, etc) Known sensitivity to propylene glycol How many time per week do you exercise? None 1 / week 2 / week 3 / week 4 / week 5 / week 6 / week Daily How much water do you drink per day? None 1-2 (8 oz) glasses 3-5 (8 oz) glasses 6-10 (8 oz) glasses More than 10 (8 oz) glasses How would you rate your eating choices? Extremely healthy Generally healthy Needs improvement What areas are you wanting to focus? Facial lines and wrinkles Double chin Flabby arms Six pack Back fat Belly fat Buttock lift Upper thighs Knees OTHER How have any other treatments / diets / exercise regimens helped with these areas in the past? What is your goal with Cryoskin? What questions can we answer about Cryoskin during your Consultation? Submit
