Cryotherapy Facial Consent Form
Please review and complete this consent form before receiving your cryotherapy facial treatment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you ever had a cryotherapy facial treatment before?
*
Yes
No
Do you have any of the following conditions? (Select all that apply)
*
Cold sensitivity (e.g., Raynaud's disease, cold urticaria)
Circulatory problems
Open wounds or sores on the face
Recent facial surgery or cosmetic procedures
Severe rosacea or eczema
Pregnancy
None of the above
Other
Please list any allergies, especially to cold, skincare products, or medications.
Are you currently taking any medications? If yes, please specify.
Do you have any other medical conditions or concerns we should be aware of?
Client Signature
*
Submit Consent
Submit Consent
Should be Empty: