Patient or Parent/Guardian Name:
Cell Phone Number:
Home/Alternate Phone Number:
Gender: Date of Birth:
*May we contact you by email and phone?
BOTH Email and Phone
Getting to Know You
How were you referred to our office?
Patient / Friend
Email / Internet Promotion
TV / Radio Commercial
What is the primary reason for your visit?
Do you go to the Gym, Spa, etc.?
*What is your average household income?
*What is your budget to spend on services provided?
What is your occupation?
*NAME of your emergency contact:
*Relationship of your emergency contact:
*Emergency contact's Phone #:
Emergency contact's email:
Skin History Questions
What is your current method of hair removal?
What is the hair color in the area of interest?
Which best describes your skin tone?
Uneven Skin Color
Which best describes the firmness and elasticity of your skin?
Loss of Firmness Elasticity
Which best describes the texture of you skin?
What is the area of interest for Cellulite Reduction/Body Contouring/Circumferential Reduction?
*Do you have or have you ever had any of the following conditions:
*Do you have or have you ever had any of the following conditions?
If you answered YES to any of the conditions listed above, please specify:
*Surgical History - Do you have or have you had?
If you answered YES to any Surgical History above, please specify:
*Medication History - Do you take?
If you answered YES to any Medications mentioned above, please specify:
*Allergies - Do you have?
If you answered YES to having any allergies mentioned above, please specify:
*Other Procedures - Have you had the following?
If you answered YES to any of the other procedures mentioned above, please specify:
*Do you use any of the following products?
If you answered YES to using any of the products mentioned above, please list the product brand name and frequency:
Skin Type Calculator
*What is your natural hair color?
*Color of your skin?
*Color of your eyes?
Light Blue, Green
Brown / Black
*Do you have freckles?
*What happens when you are overexposed to the sun?
Burns, Sometimes Peels
*To what degree does your skin turn brown (Tan)?
Hardly/Not at all
Light Color Tan
Turns Dark Brown quickly
*Do you turn brown within several hours after sun exposure?
*How does your face react to the sun?
*When was your last exposure to sun, lamps or cream?
More than 3 months
Less than 1 month
Less than 2 weeks
*Was the treatment area exposed?
*Which of the following ethic backgrounds apply to you?
|Patient or Parent/Guardian Signature:
COOLSCULPTING TREATMENT CONSENT FORM
The CoolSculpting® procedure is a non-invasive procedure that is intended to change the appearance of the treatment area by delivering controlled cooling at the surface of the skin to break down fat cells that are just beneath the skin. This procedure is not a treatment for obesity or a weight-loss solution. The CoolSculpting procedure does not replace traditional methods such as diet, exercise or liposuction.
Clinical studies of a treatment site have shown that the CoolSculpting procedure can break down fat cells to change the appearance of visibly localized bulges of fat that is just beneath the skin on the abdomen, thighs, flanks and submental area. The submental area is the area under the chin. Following the procedure, the treated fat cells are naturally processed by the body. Visible results can vary from person to person.
NO RESULTS ARE GUARANTEED
WHAT YOU CAN EXPECT:
Temporary Sensations / Symptoms:
» The suction pressure of a vacuum applicator may cause sensations of deep pulling, tugging and pinching. A surface applicator may cause sensations of pressure. You may experience intense cold, stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside during treatment as the area becomes numb.
» You may have dizziness, lightheadedness, nausea, flushing, sweating, or fainting during or immediately after the treatment.
»The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. These are all normal reactions that typically resolve within a few minutes.
» Bruising, swelling, redness, cramping and pain can occur in the treated area and the treated area may appear red for one to two weeks after treatment.
» After submental area treatment, a feeling of fullness in the back of the throat may occur. Initial if the submental area is to be treated. If the area under the chin is not being treated, please write N/A.
» You may feel a dulling of sensation in the treated area that can last for several weeks after the procedure. Prolonged swelling, itching, tingling, numbness, tenderness to the touch, pain in the treated area, cramping, aching, bruising and/or skin sensitivity also have been reported.
Potential Side Effects / Risks:
» Paradoxical Hyperplasia -- A small number of patients have experienced gradual development of a firmer enlargement, of varying size and shape, of the treatment area, known as “paradoxical hyperplasia”, in the months following the treatment. If such paradoxical hyperplasia occurs, it will be distinguishable from temporary swelling and will probably not resolve on its own. The enlargement/lump can be removed by means of a surgical procedure such as liposuction.
» Pain in the Treatment Area for up to one week after Treatment.
» Treatment area demarcation -- A small number of patients have experienced excessive fat removal in the treatment area, resulting in an unwanted indentation. The indentation may be improved through corrective procedures.
» In rare cases, patients have reported the CoolSculpting treatment area to have darker skin color, hardness, discrete nodules, frostbite (local injury due to cold), hernia or worsening of existing hernia. Surgical intervention may be required to correct hernia formation.
» Patient experiences may vary. Some patients may experience a delayed onset of the previously mentioned symptoms. Contact your physician immediately if any unusual side effects occur or if symptoms worsen over time.
» You may start to see changes in as early as three weeks after your CoolSculpting procedure, and will experience the most dramatic results after one to three months. Your body will continue to naturally process the injured fat cells from your body for approximately four months after your procedure.
» Results vary from person to person. You may decide that additional treatments are necessary to achieve your desired outcome. Although highly unlikely, it is possible that you will not experience any noticeable result from the procedure.
Pictures will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed.
As with most medical procedures, there are risks and side effects. These have been explained to me in detail. I have read the above information, and I give my consent to be treated with the CoolSculpting® procedure by Dr. Kanase and his designated staff.
CoolsCULPTING patient Photography release forM
I authorize American Laser Med Spa, Dr Neel Kanase, MD and his staff representatives, to take photographs of my body for medical purposes to be used for my patient care, marketing, literature and/or case presentations.
I understand that:
Photographs are taken to capture treatment outcomes for the Cool Sculpting® procedure.
They may be used for print, visual or electronic media including but not limited to, scientific presentations, websites and for purposes of informing the medical profession or general public about the procedure. These uses may also include marketing on behalf of American Laser Med Spa.
The images taken of me may be published by American Laser Med Spa and its agents.
I will not be identified by name in any of the published materials.
My face will not be shown in the photographs nor will they reveal my identity.
Patient or Parent/Legal Guardian:
TREATMENT AND FINANCIAL AGREEMENT TERMS, CONDITIONS, DISCLAIMERS AND REFUND POLICY (EFFECTIVE 4-14-2010)
- I fully understand and agree to treatment of the listed areas, and agree to pay American Laser Med Spa the price quoted above.
- If I have paid the price quoted using a credit program, I acknowledge that I have selected the credit program based on my own evaluation of my options. I have not relied on any recommendation or advice of American Laser Med Spa or its staff with respect to financing. I understand that American Laser Med Spa has agreements with credit program providers but does not recommend credit products to customers
- I clearly understand that my payment is for the procedure(s) performed during the term of the agreement and not for any specific result. NO RESULT IS GUARANTEED. I understand that results will vary.
- Additional treatments may be obtained at an additional price.
Refund, Cancellation and Transfer Credit policy
Your payment is based on purchasing number of treatments. Refund is based on unused treatments not based on unused time. e.g. Laser Hair Removal Series – Your payment is based on purchasing 6 treatments. NOT 2 yrs. In the 2 yr appearance plan phase (after your 6th treatment), we reserve the right when to treat you and how many times to treat you. If you receive 6 treatments, no refund is due. All refund prorating will be based on unused treatments. There is no prorating for time. e.g. If you purchased a package of 6 and received only 4 treatments in 8 months and request a refund. You have 2 unused treatments and 16 months left before your 2 yr appearance plan expires. A prorated refund (see below) will be given for 2 unused treatments, NOT based on remaining 16 months.
THIS POLICY WILL BE VOIDED IF YOU TRANSFER SERVICES TO ANOTHER LOCATION AND WILL BE REPLACED BY THE RECEIVING CLINIC’S CURRENT POLICY
If you want to cancel services and want refund –
You WILL BE charged FULL PRICE PER TREATMENT of the procedure. The price per treatment of the procedure you purchased is on our price list sheet and will be provided to you on request. All discounts (e.g. monthly specials) and credits issued when you bought the service will be lost. Service will be prorated using price per treatment listed on the price list sheet. If you earned friends and family credit - this will be LOST if you cancel/break this agreement. A prorated balance will be refunded
If you want to cancel services and don’t want a refund but want to transfer credit to another package –
You will NOT be charged FULL PRICE per treatment of the procedure to calculate prorated balance. You will be charged the price per treatment based on your package. The balance will be used towards a new package. You will be eligible for the month’s special etc. If this results in you owing money, you can pay the difference and start the new package. If this results in us owing you money, this will be kept as credit for future use. (Credit expires 90 days from new purchase).
If you don’t see results even after 2 yrs of treatments for Laser Hair Removal - NO REFUND is due. You can buy a new package at 2 yr appearance plan (maintenance) price.
If you are burned or have other adverse event – NO REFUND is due. This is part of the risk of the procedure and was explained to you when you signed the contract. Our goal is to eliminate/minimize the risk of burn or any other adverse event, but we want to be upfront with you so you can make a well informed educated decision.
- No Show Fee - $75. If you do not show up for your scheduled appointment
- Cancellation Fee - $75. If you cancel appointment without giving us a 24hr notice
- Shaving Fee - $75. If you come in without shaving (exception – first treatment or unless we asked you not to shave)
- Photocopying Fee - $10. For a copy of your records. Need a written request.
I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE.
|Patient or Parent/Guardian Signature: