CoolSculpting Treatment Form

I certify that I am a competent adult of at least 18 years of age

I certify that I am a minor under the age of 18 and understand that the consent of my parent/legal guardian will also be required before treatment.

I understand the CoolSculpting® procedure is a non-invasive procedure that is intended to break down fat cells that are just beneath the skin by delivering controlled cooling at the surface of the skin. This procedure is not a treatment for weight loss.  The CoolSculpting procedure does not replace traditional methods such as diet, exercise, or liposuction.  *

I understand visible results can vary from person to person.*

I understand the suction pressure of a vacuum applicator may cause sensations of deep pulling, tugging, and pinching, and that a surface applicator may cause sensations of pressure. *

I understand I may experience intense cold, stinging, tingling, aching or cramping as the treatment begins. These sensations generally subside during treatment as the area becomes numb.  *

I understand the treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur.*

I understand bruising, swelling, redness, tenderness, cramping, and aching can occur in the treated area and the treated area may appear red for one to two weeks after treatment.*

If the area being treated is under the chin or jawline, I understand after submental or submandibular area treatment, a feeling of fullness in the back of the throat may occur.*

I understand I may feel numbness 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 have also been reported. Numbness can last for several weeks after the treatment.*

I understand Paradoxical Hyperplasia is a potential side affect/risk.*

I understand I may experience late-onset pain with a typical onset several days after a treatment and resolution within several weeks.*

I understand I may have dizziness, light-headedness, nausea, flushing, sweating, or fainting during or immediately after the treatment. *

I understand Treatment Area Demarcation is a potential side affect/risk.*

I understand some patients have reported the following conditions in areas of the body treated with CoolSculpting®: darker skin color, hardness, discrete nodules, burns, frostbite (local injury due to cold), nerve pain, extensive tissue damage, and fat necrosis. I also understand surgical intervention may be required to address these conditions if they develop.*

I understand some patients have reported development of a hernia, or worsening of an existing hernia, following CoolSculpting treatment. I also understand surgical intervention may be required to correct hernia formation or exacerbation.*

I understand skin laxity can also develop in the treated area and surgical intervention may be required for correction.*

I understand patient experiences may vary, and some patients may experience a delayed onset of the previously mentioned symptoms. I agree to contact my physician immediately if any unusual side effects occur or if symptoms worsen over time. *

I understand that any of these known side effects may occur and there is no way to predict who may experience them. *

I understand that other unknown side effects may also occur following CoolSculpting® treatment, but elect to voluntarily proceed with CoolSculpting®.*

I certify no one associated with the medical practice or the manufacturer of CoolSculpting® has provided any information which contradicts any of the risks that have just been described.*

I understand I may start to see changes in as early as 1-3 months after my CoolSculpting procedure and that my body will continue to naturally process the injured fat cells from your body for months after your procedure.*

I understand results vary from person to person and that I may decide additional treatments are necessary to achieve your desired outcome. Although highly unlikely, I understand it is possible that I will not experience any noticeable result from the procedure. *

I understand that particular results cannot be guaranteed, given that each body may react differently to stimuli. *

I understand pictures will be obtained for medical records. If pictures are used for education and marketing purposes, all identifying marks will be cropped or removed. *

I consent to allowing Mirage Salon & MedSpa to use the photographs on their social media for promotional purposes.