Online Cryotherapy Consent Form Copy

First name *

Surname *

Address *

Postcode *

Date of Birth *

Contact Number

Have you or anyone in your household had COVID-19? *

Do you have or have you had a high temperature in the last 7 days? *

Please select the treatment you require an appointment for *

If you treatment is not in the list, please call the clinic

Cryotherapy

THE FOLLOWING POTENTIAL ADVERSE EVENTS HAVE BEEN FULLY EXPLAINED AND UNDERSTOOD BY ME:
Possible side effects may include redness, swelling, blistering, pain, itching, discoloration and rarely headaches when areas of the scalp are treated.  Any damage to nerves (on very supercial treatments such as hands) will return to normal after time. Areas treated on sites with coarse hair, the follicles are easily damaged with crypotherapy and may result in alopecia. The proportionate risk has been explained to me. I will advise my Practitioner should I experience any of the aforementioned adverse events and that I have made aware of any upcoming events that these side effects may have an impact on.
I understand that more than one treatment session may be required to obtain maximum effects and no guarantee can be given as to the results of the treatment referred to in this document. I accept and understand that the goal of this treatment is improvement not perfection.
I confirm that to the best of my knowledge that the information that I have supplied is correct and that there are no other medical information that I need to disclose.
I confirm that I will apply SPF50 to treated ares. 
I consent to receiving treatment with Cryotherapy as discussed with my Practioner regarding the procedure I will be undertaking, understand the information given, potential risks and that any medical terminology,  questions or queries  have been answered. I am aware of alterative treaments and that to have no treatment is one of those options.

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