CryoSkin and Kassen Life Consultation Cryo Solihull Name(Required) First Last Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)GP Details(Required) Occupation(Required) The information above is for your therapist's record only and will not be misused or passed on to any third parties, unless with my authority.(Required) I agreePermanent Contraindications for Cryoslimming/Toning/Facial (treatment cannot be carried out) Cryoslimming or CryoToning are possible on spider veins without the initial warm phase. A CryoFacial is possible on people suffering from osteoporosis.(Required) Do you suffer from Cryoglobulinemia auto-immune disease? Do you suffer from allergies to cold (irritated skin, Raynaud syndrome)? Do you have any serious blood circulation conditions (phlebitis, severe varicose veins)? Do you have a hernia in the treatment zone? Do you have heart disease? Acne? Burns/Grafter skin? Polycystic ovarian syndrome? Herpes (cold sores)? Do you suffer from Osteoporosis (level 3)? Are you pregnant or could be pregnant? I have cancer or have had cancer or radiation/chemotherapy? I have none of the above Temporary Contraindications for CryoSlimming/Toning/Facials. Sometimes localised redness can occur during this treatment, or the client might feel some discomfort or itching without consequences and often due to the reactions with certain cosmetic products - these side effects usually disappear within 72 hours. No CryoSlimming/Toning until menustration return or the end of breast feeding. A CryoFacial is possible if breast feeding. A treatment is possible if the area has completely healed (tattoos) and any piercings must be removed.(Required) I am over 18 years old Are you breast feeding? Have you got any skin condition in the treatment zone - wound/scar (less than 3 months) eczema etc? Have you recently had any body piercing/tattoos in the treatment zone? I have none of the above Contraindications for CryoSlimming (fat freezing)(Required) New or suspected deep vein thrombosis or thrombophlebitis* Any Pain or numbness anywhere in the area* Hirtsutism Keloid formations/Scars Liver/Kidney disease Melanoma/Moles Port wine stain Epilepsy Haemangioma Psoriasis Shingles Skin pigmentation Steroid of Hormonal therapy Viltligo Thyroid hormone deficiency Hormonal Imbalances Lupus Disease Aids Clotting disorders Gold Injections Anti-inflammatory medication Haemophilia Pregnant or could be pregnant Anti-coagulants Peripheral neurpathy Peripheral vascular disease Severe arteriosclerosis or "ischemic"vascular diseases* Gangrene* Dermatitis Untreated or infected wounds* Severe inflammation of the skin* Recent skin grafts* Do you have any heart conditions? Do you suffer from circulatory problems in your legs or arms?* Have you had any operations with the last 3 years? Do you have any electronic implants in your body?* Medical consent required Do you have any metal objets in your body? Are you under any medical treatments at this present time?* Do you have any allergies - If yes please provide further details Are you taking HRT? Are you taking any medication - if yes please provide further details Do you suffer any respiratory problems? Do you have epilepsy? Do you have diabetes or any other metabolic illness?* Medical consent required - treatment can be carried out every 3 weeks Do you have or had any type of cancer?* Do you have any thyroid conditions? Do you have any kidney problems?* Do you have any liver conditions?* Do you have any varicose veins?* Have you had any organ transplants?* Are you in menopause pre/post? I have none of the above Please provide further details if you have answered ticked any of the above to help us gain a better understanding as some some of the conditions indicate No treatement Contraindications for CryoToning/CryoFacial - Please note that is possible to do a CryoToning/Facial treatment every week on the same zone. It is possible to do more than one treatment per week on different zones ie face/legs. Have you had Botox/Hyaluronic fillers in the last 3 months? (CryoFacial only) Do you have any sinus sensitivity? (CryoFacial only) Do you have breast implants (CryoToning targeting the breasts only) None of the above The information above is for the therapist's record only and will not be misused or passed on to any third parties, unless with authourisation of the client. Disclaimer: I declare that I have read, understood and answered the questions to the best of my knowledge. I have no known medical condition or allergies that may affect or induce a harmful reaction from a CryoSlimming (fat freezing) or a CryoToning/CryoFacial treatment. If you have a specific condition that is not mentioned in the lists above, you should ask your doctor for medical advice. Your therapist might refuse to conduct a CryoSlimming or CryoToning/CryoFacial treatment as a precaution. I fully understand the above and what the treatment entailsPlease provide any further details that may help us with your treatment below: Please note our cancellation policy is 48 hours - less than 48 hours full cost of the appointment will be charged.(Required) I agree to this policy. And give consent to Cryo Solihull to store my details under GPDR compliance.Date MM slash DD slash YYYY Δ