Pure Cryo Wellness New Client Intake & ConsentPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.First name / Last nameFirstLastEmailEmergency contact nameHow did you hear about us?Word of mouthFacebookInstagramSearch engineInfluencerWhat is the main goal that you would like us to help you achieve?Post-injury or post-surgery RECOVERYAthletic RECOVERYPAIN reliefFirming, toning, tightening of the SKIN in select parts of the bodyLessening of FAT depositsCELLULITE reductionAnti-AGINGDOUBLE CHIN reductionManagement of a SKIN CONDITIONOtherAre you pregnant?YNDo you have any cold-induced condition, such as cold hemolysis, cryoglobulinemia, cold agglutination, cold allergies, or other?YNAre you hyper- or hyposensitive to cold?YNDo you have a blood disorder related to coagulation?YNDo you have cancer or undiagnosed lumps?YNIn or around the intended treatment area: Have you had Botox or fillers in the last 2 weeks?YNDo you have any open wounds or lesions?YNIs your skin sunburn or frostbitten?YNConsent to use the clinical photographs: Please CHOOSE ONECONSENT TO OPEN PUBLICATIONCONSENT TO RESTRICTED EDUCATIONAL USECONSENT TO CASE NOTES ONLY the use or Authorization, waiver, and consent: I amthe clienta parent/legal guardian of the client under 18Submit
