INFORMED CONSENT FORM FOR CRISTAL PRO

Informed Consent Form For Cristal Pro

The principle of CRISTAL PRO® cryolipolysis is to practice a sustained suction of tissues while diffusing a controlled cooling on the surface of the skin. This technique leads to a reduction of fat mass in the targeted area. This is not a weight loss solution and it does not replace traditional methods such as liposuction. An overweight patient should expect less improvement than one with smaller fat deposits. Clinical studies have shown that CRISTAL PRO® cryolipolysis naturally destroys fat cells. However, as with most techniques, the results vary from one individual to another.

OBSERVED EFFECTS

  • The phenomenon of suction can cause feelings of deep tugging and You may experience intense tingling, pain or cramps at the beginning of the treatment. These sensations usually stop as the treated area becomes numb.
  • The treated area may have a rigid appearance (observed and felt) as a result of the A temporary whitening of the skin can be observed. It is possible to feel nausea and vertigo, your body reacting to the treatment. These reactions are normal and usually go away in minutes.
  • Bruises, swelling, and tenderness may appear on the treated area as well as redness of the skin that may persist for several hours after the Subcutaneous induration, lumps with pain and / or discomfort as well as hyperpigmentation with dark coloration of the skin may appear at the site or at the edge of the treatment area.
  • You may experience a loss of sensation in the treated area for several weeks after the treatment. Other observable changes - including severe itching, tingling, numbness, tenderness, pain in the treated area, severe cramps and painful muscle contractions - are the main adverse effects observed after a cryolipolysis treatment.
  • The effects differ among patients and a late onset of the previously mentioned effects has been observed (1 to 2 weeks after treatment). Contact us immediately if any side effects not listed appear or if symptoms
  • Burns may also be observed in some patients as well as brown skin coloration, stiffness and hypoesthesia or deformity of the treated area. Surgery may be required to correct this deformity. Late-onset pain can also occur.
  • Vasovagal episodes during or immediately after treatment may be observed in some
  • Paradoxical hyperplasia (PAH) may occur 2 to 9 months after PAH is an increase in the volume of fatty tissue treated. In this case, contact us immediately.
  • Contact us immediately if any side effects mentioned or not mentioned appear, or if symptoms
  • You can see results as early as 4 to 6 weeks after cryolipolysis treatment and the more results after three months. Your body continue to naturally eliminate damaged fat cells for up to four months after the treatment
  • It is possible to perform several sessions until the desired result is

 

I have been informed of these side effects and that some other unknow ones may appear.

DO YOU HAVE ONE OR MORE OF THE FOLLOWING CONDITIONS?

Please circle the answer.

Formal contraindications:

If one of the answers surrounded is «YES» you will not be able to be treated with cryolipolysis.

Cryoglobulinemia
Cold paroxysmal hemoglobinuria
Cold agglutinin disease
Known sensitivity to cold such as cold urticaria
Hernia at or near the treatment site
Pregnancy and breastfeeding
Known sensitivity to cold such as Raynaud's disease, frostbite
Altered peripheral circulation in the area to be treated
Neuropathic disorders or neurological impairment, nerve pain (post-herpetic neuralgia or diabetic neuralgia) Yes / No
Skin conditions (eczema, dermatitis, rashes, open or infected wound)
Bleeding disorders or simultaneous use of anticoagulants
Recent surgery or scar tissue in the area to be treated
Active implantable device such as pacemaker or defibrillator
Bleeding disorders or simultaneous use of anticoagulants
Recent surgery or scar tissue in the area to be treated
Active implantable device such as pacemaker or defibrillator
Bleeding disorders or simultaneous use of anticoagulants
Recent surgery or scar tissue in the area to be treated
Precautions of use:
Chronic pain or chronic conditions requiring treatment
Infectious and fever, anxiety
Known sensitivity or allergy to isopropyl alcohol, propylene glycol, fructose or glycerin
I have read the formal contraindications and precautions for the use of cryolipolysis.

I have read the above information, and I agree to be treated with cryolipolysis CRISTAL PRO® by the Doctor of Padra Medical Center and their assistant.