CoolSculpting Consent - Fusion Medical Aesthetics

The CoolSculpting® procedure uses a non-invasive vacuum applicator to draw in tissue and deliver controlled cooling at the surface of the skin. The procedure is for spot reduction of fat. It is not a weight-loss solution and it does not replace traditional methods such as liposuction. Someone who is overweight can expect to see less visible improvement than someone who has smaller fat deposits. Clinical studies have shown that CoolSculpting will naturally remove fat cells but, as with most procedures, visible results will vary from person to person. (INITIALS)*

WHAT YOU CAN EXPECT:

The suction pressure may cause sensations of deep pulling, tugging and pinching. You may experience intense stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb. (INITIALS)*

The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. You may feel a sense of nausea or dizziness as your body naturally warms and sensation returns to your treatment area. These are all normal reactions that typically resolve within minutes. (INITIALS)*

Bruising, swelling, and tenderness can occur in the treated area and it may appear red for a few hours after the applicator is removed. (INITIALS)*

You may feel a dulling of sensation in the treated area that can last for several weeks after your procedure. Other changes – including deep itching, tingling, numbness, tenderness to the touch, pain in the treated area, strong cramping, muscle spasms, aching and/or soreness – also have been reported after a CoolSculpting treatment. (INITIALS)*

Patient experiences will differ. Some patients may experience a delayed onset of the previously mentioned occurrences. Contact us immediately if any unusual side effects occur or if symptoms worsen over time. (INITIALS)*

You may start to see changes as early as three weeks after CoolSculpting, and you will experience the most dramatic results after one to three months. Your body will continue naturally to process the injured fat cells from your body for approximately four months after your procedure. (INITIALS)*

You may decide that additional treatments are needed to reach your desired outcome. (INITIALS)*

In rare cases, patients have experienced vasovagal symptoms during the treatment, and reported freeze burn, darker skin color, hardness, discrete nodules or enlargement of the treatment area. Surgical intervention may be required to correct the enlargement. I understand that these and other unknown side effects may also occur. (INITIALS)*

DO YOU HAVE ANY OF THE FOLLOWING?

Cryoglobulinemia or paroxysmal cold hemoglobinuria*

Yes
No

Known sensitivity to cold such as cold urticaria or Raynaud’s disease*

Yes
No

Impaired peripheral circulation in the area to be treated*

Yes
No

Neuropathic disorders such as post-herpetic neuralgia or diabetic neuropathy*

Yes
No

Impaired skin sensation*

Yes
No

Open or infected wounds*

Yes
No

Bleeding disorders or concomitant use of blood thinners*

Yes
No

Recent surgery or scar tissue in the area to be treated*

Yes
No

A hernia or history of hernia in the area to be treated*

Yes
No

Skin conditions such as eczema, dermatitis, or rashes*

Yes
No

Pregnancy or lactation*

Yes
No

Any active implanted devices such as pacemakers and defibrillators*

Yes
No

Pictures will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed. (INITIALS)*

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 CoolSculpting® by Dr. Lisa Gardner and her designated staff.

Name*

Name

Date*

Signature*

Witness

Name

Date

CoolSculpting Consent Form