New Client Intake Form & Consent

To enable us to ensure your comfort and safety in all services we provide, please, take time to carefully read this form and answer ALL QUESTIONS to the best of your ability.

All provided information is CONFIDENTIAL and protected – we will never share it with any 3rd parties, unless required by law.

Introduction. What is localized high impact cryotherapy

For localized cryotherapy services, we use one of the newest and most effective technologies on the market - a device called the Subzero by America Cryo.

The procedure includes spraying the treatment area with dry vapor of carbon dioxide (CO2), as cold as -108° F, under pressure as high as 50 bar, in short 90-second increments. The combination of precise targeting, extremely low temperatures, and strength of the flow result in more rapid and deeper cooling of the affected tissue, producing better results faster.

This technique is not considered a medical treatment, but rapid cooling of the skin and underlying tissue can be used for pain management, stimulation of cell regeneration, tightening and brightening of the skin, anti-aging facials, and reduction of stubborn fat deposits and cellulite.

Thermal shock improves blood flow in the treatment area and helps reduce inflammation. If applied to fat cells that are more sensitive to cold than any other cell in the body, cooling triggers a process called cryolipolysis and results in apoptosis – controlled permanent destruction of subcutaneous fat tissue.

Localized cryotherapy is safe for most people, but some contraindications have been identified and negative side effects are possible. Familiarizing yourself with the below information will help you avoid unwanted consequences.

Part I. Tell us about your goals and history of health conditions

Please note that this list is indicative but not exhaustive - if you have any injury, illness, a serious medical condition, or a health-related concern, we strongly suggest consulting a physician prior to using localized high impact cryotherapy.

Part II. Advisements and contraindications

Having any of the contraindications described in this document will require you to use discretion for your own well-being.

Cold applications can feel slightly uncomfortable and leave the skin pink for a short period following the session, while the skin temperature is returning to normal, but there is no damage and no recovery required. In case of experiencing burning sensation, pain, or significant discomfort at any time during our treatments, we strongly advise you to terminate the session immediately upon your own volition.

Localized high impact cryotherapy for pain management

We use a high-pressure flow of gasiform CO2 to lower the tissue temperature in the treated area. The process called cryostimulation causes constriction of the blood vessels in response to cold, followed by dilation and improved blood flow post-treatment, reducing inflammation and swelling and stimulating release of hormones like noradrenaline and Beta-Endorphins which are powerful natural pain killers. Applications include athletic recovery, recovery from soft tissue, muscle, tendon, or overuse injuries or surgery, and painful motion-limiting medical conditions.

This treatment does not impose health risks but should NOT be applied to highly sensitive skin or open wounds and should be avoided in case of cold allergies or any other cold-induced condition.

Localized high impact cryotherapy for fat freezing/body sculpting

In this process, we use a phenomenon called cryolipolysis. Cooling the problem areas to the point when subcutaneous fat cells, that are very sensitive to low temperatures, get damaged and die, leads to gradual slimming. Post treatment, the body uses the lymphatic system to permanently expel the damaged cells.

Because of the strain that the need to eliminate the cellular debris puts on the body, you should NOT do fat freezing treatments if you are pregnant, undergoing dialysis, having only one kidney or any type of kidney or liver disease, or impaired circulatory system. Being oversensitive or allergic to cold, having active cancer, or going through chemotherapy are also contraindicated.

High impact cryo facials

Cold applied to the face, neck, or decolletage causes blood vessels to constrict, then dilate, improving circulation and making the skin look firmer and better toned. The process also soothes inflammation, helps fight bacterial infections like acne and stimulates collagen production that has anti-aging effect.

You should NOT use cold if you are cold-intolerant or your skin is highly sensitized by sun or treatments like chemical peels. You should take a 2-week break after procedures like Botox or fillers.

Part III. Liability waiver

In consideration of using the localized cryotherapy services offered by EliteCryo, USA and by filling out and signing this Intake Form prior to or during your first visit, you have acknowledged the following:

You have been truthful in disclosing your current health condition, as well as past health-related events, including but not limited the ones listed as definite contraindications.

You understand that the services provided by EliteCryo,USA, although they may have certain health benefits, have been designed to enhance health, appearance and vitality in generally healthy individuals. You have been advised that all services have contraindications and that you should ONLY use any treatments if you either don’t have the related risks or have discussed these risks with your doctor and obtained their written consent.

You recognize the importance of informing EliteCryo,USA personnel about any changes in your health condition, including pregnancy, as they may compromise effectiveness and/or safety of the services you will be receiving.

You are aware of the need to postpone your appointments with EliteCryo,USA if you are feeling sick and have symptoms like fever, congestion, cough, shortness of breath, chest pain, dizziness, nausea, rash, or if you have an acute infection of any kind. The EliteCryo,USA cancellation requirements and package expiration dates still apply.

You have been informed that results, especially when it comes to fat loss, cellulite, or aging, are not always immediate, and some benefits will continue to develop over weeks, or even months, post-treatment. Because your body and lifestyle are unique, so will be your progress. In some cases, treatment may not be successful, especially if you fail to follow treatment number and frequency recommendations given to you by the EliteCryo,USA staff. Commitment to a minimum 5 sessions, followed by a proper maintenance protocol is paramount for success.

You consent to commit to promptly following all safety and other behavior and treatment-related instructions. The post-treatment safety instructions are included in this waiver and are also available as a downloadable PDF.

You accept the responsibility to immediately inform EliteCryo, USA if you feel discomfort or experience any adverse effects from any treatment that you are undergoing, as they may indicate the need to discontinue the service.

You confirm that it has been explained to you, and you understand the administration of the localized high impact cryotherapy services provided by EliteCryo, USA, including possible adverse reactions, side effects, or complications. They are rare, but, when extreme cold is involved, minor frostbites may occur and may lead to long-term sensitivity of the affected area to heat or cold post-event.

Based on the above, YOU VOLUNTARILY ASSUME FULL RESPONSIBILITY for engaging in the said services and AGREE TO INDEMNIFY AND HOLD EliteCryo, USA from any consequences and related costs that may incur due to your use of any of the treatments.

You also acknowledge that you have been given no warranty or guarantee of any particular results. You understand that the outcome depends not only on the treatments, but also diet, lifestyle choices and numerous other factors outside EliteCryo, USA’s control.

Part IV. Consent to use the clinical photographs

Except for pain management, clinical photographs play a key role in monitoring your progress over the weeks of treatment and education of our staff. They also help inform equipment suppliers in the process of continuous development of new applications and better technologies.

Different types of consent are required according to the way in which clinical images will be used. Please CHOOSE ONE of the options below. If you do not fully understand what each option implies, please ask. Please note that we must take photographs to monitor your progress; so, at least the lowest level of consent (case notes) is REQUIRED.

Your choice of consent level will not affect your treatment in any way.

Post-Cryotherapy Safety & Aftercare Instructions

Please read these instructions carefully and follow them after every localized CO₂ cryotherapy session, including cryo facials, body contouring, and wellness or spot treatments. A standalone copy is also available as a downloadable PDF.

What you may notice

Temporary redness, tingling, numbness, or a feeling of tightness in the treated area is common and usually settles as the skin returns to a normal temperature. The skin may feel cooler or slightly more sensitive for a short time.

When to contact EliteCryo or seek medical care

Contact EliteCryo promptly if you notice blistering, persistent or worsening pain, unusual or lasting changes in skin color, or any signs that concern you, including possible frostbite (for example, skin that stays very pale, gray, or hard, or blisters after treatment). Seek medical care if symptoms are severe, rapidly worsening, or if you are unsure whether you need urgent attention. For aftercare questions, call (805) 864-2012 or email info@elitecryousa.com.

For about 24 hours after treatment

• Avoid heat on the treated area, including hot tubs, saunas, and very hot showers.
• Avoid intense exercise that significantly raises body temperature or puts strain on the treated area.
• Avoid direct sun on the treated area. When you are outdoors, use a broad-spectrum sunscreen (SPF).
• Do not apply ice packs or heat packs to the treated area unless EliteCryo or your physician has specifically advised it.

Skin care

• Gently pat the skin dry; do not rub.
• Stay well hydrated.
• After facial treatments, avoid harsh active products on the treated area — including retinoids, acids, and physical or chemical exfoliation — for 24 to 48 hours, or longer if your skin still feels sensitive.
• You may use a gentle moisturizer if the skin feels dry, unless you have been given other directions.

Time between sessions

Keep the recommended gap between sessions. EliteCryo will advise you on an appropriate interval for your treatment plan. Do not schedule more frequent sessions on your own.

Important disclaimer

These instructions are general aftercare guidance for localized cryotherapy and are not medical advice. They are not a substitute for care from a licensed clinician. Follow your physician’s guidance, especially if you have a medical condition, take medication, or have been told that cold therapy may not be appropriate for you. If anything in these instructions conflicts with advice from your physician, follow your physician.

EliteCryo USA Beauty + Wellness · (805) 864-2012 · info@elitecryousa.com

Authorization, waiver, and consent

I hereby confirm that all information provided by me herein is correct to the best of my knowledge, and I have disclosed all health-related risk factors that I know of. I understand that treatment safety may depend on my health status.

By signing this document, I CONFIRM THAT I HAVE READ, UNDERSTOOD AND AGREED with the treatment-related risks, liability waiver, and provisions of the EliteCryo, USA Service Terms and Conditions. By signing this document, I ALSO CONFIRM THAT IT HAS BEEN EXPLAINED TO ME AND I AGREE with the choice of consent level related to the use of the “before” and “after” photographs.

I am aware that, to withdraw my earlier given consent, that I could do any time without any impact on the services I will be receiving, I must request it in writing.

You can also download a PDF copy after you submit. An automatic email of that PDF to your inbox is not set up yet; if you check this box, EliteCryo will see that you requested a copy.