CryoClear is a new way of treating your skin to remove skin tags, age spots and sun spots. Before beginning any treatments with CryoClear, it is important for you to be informed about the treatment including the potential benefits and risks. This will allow you to make an informed decision to consent or withhold any treatment program. It’s suggested that you take time to read the information below along with any accompanying literature about CryoClear as you make your decision on whether or not to begin or not to begin a treatment. I have requested treatment at The Day Spa using CryoClear on sun spots, age spots/or skin tags. I understand that the practice of aesthetic medicine is not a precise and there is no guarantee of expected results. I also understand that several treatments may be necessary to complete the treatment. Potential Risks and Side Effects: CryoClear works by freezing the area on the skin where it is sprayed with liquid nitrogen. Each spot is sprayed for 5-10 seconds. Following treatment, you may feel some tingling and redness. Over the next few days, the area will darken, followed by treated skin slowly falling off and new skin appearing in its place in about 10-14 days. Occasionally, following treatment, you may experience mild discomfort erythema or loss of pigmentation at the treatment site. We recommend that you clean the area with soap and water daily and supply Tissue Repair Cream by M’lis during and after the healing stages. I have been advised on the risks associated with treatment using CryoClear along with the potential benefits and alternative treatments including no treatment at all. You must agree before submitting. Date Of Appointment (Month/Date/Year) Client's Name Date Today (Month/Date/Year) Phone Address City State Zip Health History : Have you previously received Cryo-treatment? - Select - Yes No If yes, when and where on body? Do you have any skin reactions? - Select - Yes No If yes, please list:
