TREATMENT CONSULTATION FORM

The CoolSculpting® procedure may use a non-invasive vacuum applicator to draw in tissue or a non-invasive surface applicator to 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 the CoolSculpting procedure will naturally remove fat cells but, as with most procedures, visible results will vary from person to person. Initial:

What you can expect:

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 stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside as the area becomes numb. Initial:

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. Initial:

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

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 procedure. Initial:

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. Initial:

You may start to see changes as early as three weeks after your CoolSculpting procedure, 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. Initial:

You may decide that additional treatments are needed to reach your desired outcome. Initial:

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. Treatment may cause new hernia formation or exacerbate pre-existing hernia, which may require surgical repair. I understand that these and other unknown side effects may also occur. Initial:

Do you have any of the following? :

Cryoglobulinemia or paroxysmal cold hemoglobinuria .............................................................

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

Impaired peripheral circulation in the area to be treated ..........................................................

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

Impaired skin sensation ............................................................................................................

Open or infected wounds ..........................................................................................................

Bleeding disorders or concomitant use of blood thinners .........................................................

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

A hernia or history of hernia in the area to be treated or adjacent to treatment site .................

Skin conditions such as eczema, dermatitis, or rashes ............................................................

Pregnancy or lactation ..............................................................................................................

Any active implanted devices such as pacemakers and defibrillators ......................................

Pictures will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed. Initial:

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. and designated staff.

Print Name:

Witness:

PATIENT PHOTOGRAPHY RELEASE FORM

Person Name:

I, , authorize , and 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 CoolSculpting® 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 .

The images taken of me may be published by 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.

I have the right to revoke this authorization in writing at any time through a written revocation to .

I hereby release , and its agents from any and all claims and demands arising out of, or in conjunction with, the use of the photographs.

I certify that I have read this release carefully and fully understand its terms. If I have any questions I can contact at .

If under 18, guardian or parent must sign.

Print Name:

Witness: