Tell Us About You…

AREAS OF CONCERN *

PLEASE CHECK ALL THE AREAS THAT ARE OF CONCERN.

Face

Neck, Decolletage

Shoulders, Chest

Arms

Stomach

Love Handles

Hips

Inner Thighs

Front Of Thighs

Buttocks

Back Of Thighs

Knees

Ankles

NAME *

First Name

Last Name

BIRTHDATE *

MM

DD

YYYY

TREATMENT HISTORY *

Have you ever tried any other aesthetic procedures in the past?

YES

NO

HOW DID YOU HEAR ABOUT CRYOSKIN *

Please check all that apply.

Friend/Family

TV/Radio

Internet

Other

YOUR BACKGROUND INFORMATION *

Please check all that apply: I have had...

Botox in the past 30 days

Fillers in the past 90 days

Surgery in the past 6 months

Breast implants

Pregnant and/or breastfeeding

Active/Past Cancer

Kidney and/or Liver disease

Uncontrolled Diabetes

Lymphatic disorders

Uncontrolled Diabetes

Severe allergy to cold

Severe Raynaud’s Syndrome

Eczema, rashes, or dermatitis

Open or infected wounds

Circulation disorders

Pacemaker/metal implants

Mesh inserts

Incision scar(s) in the desired area

HIV/AIDS

Body piercings in the desired area

Using topical antibiotics

Progressive diseases (MS, ALS, etc.)

None

YOUR DIET *

How would you rate your diet?

Extremely Healthy

Generally Healthy

Need Improvement