Please Complete The Following Consent Form
The purpose of this consent form is to provide written information regarding the risks, benefits and alternatives of CoolSculpting treatment. This material serves as a supplement to the discussion you have with your BLOOM HEALTH provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the procedure, ask your Bloom Health provider prior to submitting this consent form.
TREATMENT GOALS AND DESCRIPTION OF PROCEDURE
CoolSculpting is a non-invasive procedure that delivers controlled cooling at the surface of the skin to break down underlying fat cells. The procedure decreases the appearance of localized bulges of fat that are just beneath the skin. Treatment areas include the abdomen, flanks, thighs, underarms, and chin. Following the procedure, the treated fat cells are naturally processed and removed by the body. This procedure is not a treatment for obesity or a weight-loss solution. The CoolSculpting procedure does not replace traditional methods such as diet, exercise and healthy lifestyle. During the procedure, the cooling applicators are applied for 35 to 75 minute cycles. You may feel some pinching and pulling as the suction applicators draw up fat between the cooling plates. After about 5-10 minutes, the treatment area becomes numb. After each cycle, a vigorous massage is performed on the area to enhance the destruction of fat cells, and patients may experience some temporary pain. The treated area may look or feel stiff after the procedure and transient blanching (temporary whitening of the skin) may occur. These are normal reactions that typically resolve within a few minutes.
TREATMENT RESULTS
Most patients are pleased with the results of their CoolSculpting treatment. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that the treated fat bulges will disappear completely, or that you will not require additional treatment to achieve the results you seek. Multiple treatments are usually needed to achieve a full effect, with a usual recommendation of 1-3 treatments for each body area, spaced about 6 weeks apart. The results of treatment are dependent on many factors including but not limited to: age, tissue conditions, and your general health and lifestyle conditions. Results may be visible as early as 3 weeks after your CoolSculpting procedure, and you will experience the most dramatic results after 1-3 months. Your body will continue to naturally process the injured fat cells from your body for about 4 months after your procedure. Although highly unlikely, it is possible that you will not achieve any noticeable result from the procedure.
AFTERCARE INSTRUCTIONS
Following your CoolSculpting procedure, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) You may resume normal activities immediately following the procedure; 2) Okay to take Tylenol, NSAIDs, or oral arnica for post treatment discomfort; 3) You may experience temporary pain, redness, swelling, or bruising for up to 2 weeks; 4) You may experience temporary numbness in the treated area, which can last up to 8 weeks; 4) You may experience temporary discoloration of the urine, which will resolve on its own; 5) Continue your healthy lifestyle and diet plan; 6) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e., BLOOM HEALTH, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me during my visit.
POTENTIAL RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy. I understand that there are certain inherent and potential risks and side effects in any procedure, and in this specific instance such risks include but are not limited to: 1) dizziness, lightheadedness, nausea, flushing, sweating, or fainting during or immediately after the treatment; 2) Temporary bruising, swelling, redness, cramping and pain can occur in the treated area, and the treated area may appear red for 1-2 weeks after treatment; 3) You may feel a dulling of sensation in the treated area that can last for several weeks after the procedure; 4) Prolonged swelling, itching, tingling, numbness, tenderness to the touch, pain in the treated area, cramping, aching, bruising and/or skin sensitivity also have been reported; 5) Paradoxical hyperplasia: A small number of patients have experienced gradual enlargement of the treatment area, with varying size and shape, in the months following treatment (known as “paradoxical hyperplasia”). If such paradoxical hyperplasia occurs, it will be distinguishable from temporary swelling and will probably not resolve on its own. The enlargement/lump can be removed by means of a surgical procedure such as liposuction; 6) Treatment area demarcation: A small number of patients have experienced excessive fat removal in the treatment area, resulting in an unwanted indentation. The indentation may be improved through corrective procedures; 7) In rare cases, patients have had darker skin color, tissue hardness, discrete nodules, frostbite (local injury due to cold), hernia or worsening of pre-existing hernia in the treatment area. In some cases, surgical intervention may be required to address these problems.
PREGNANCY AND CONTRAINDICATED CONDITIONS
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I do not have cryoglobulinemia (a condition in which an abnormal level of proteins thicken the blood in cold temperatures); paroxysmal cold hemoglobinuria; or cold agglutinin disease (blood disorders in which cold temperatures lead to red blood cell death). I do not have known sensitivity to cold such as cold urticaria (hives triggered by cold); Raynaud’s disease (disorder in which cold leads to reduced blood flow in the fingers, which appear white, red, or blue); pernio or Chilblains (itchy and/or tender red or purple bumps that occur as a reaction to cold). I do not have poor blood flow in the area to be treated; neuropathic (nerve) disorders such as post-herpetic neuralgia or diabetic neuropathy; impaired skin sensation; open or infected wounds; bleeding disorders or use of blood thinners; recent surgery or scar tissue in the area to be treated; a hernia or history of hernia in the area to be treated or adjacent to treatment site; any active implanted devices such as pacemakers and defibrillators; any major health problems such as liver disease; any known sensitivity to isopropyl alcohol (rubbing alcohol) or propylene glycol.
ALTERNATIVE THERAPY
I understand that this is an elective procedure with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Other non-invasive bodysculpting therapies might include radiofrequency, ultrasound, heat, or lasers modalities. The obvious surgical alternative to CoolSculpting is liposuction.
PAYMENT
I understand that CoolSculpting is not covered by insurance, and payment is my responsibility and is expected at the time of treatment.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue the procedure at any time.
RELEASE OF LIABILITY
I hereby indemnify BLOOM HEALTH, PLLC from any liability relating to the procedures that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
CONSENT TO TREATMENT
By entering my initials below, I hereby voluntarily consent to treatment with CoolSculpting for the purpose of fat reduction in the abdomen, flanks, thighs, underarms, chin, or other areas, as performed by my BLOOM HEALTH provider, and assistant technicians. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective procedure and I understand that no guarantees are implied as to the outcome of the procedure. Please note this consent is valid for all future CoolSculpting treatments I choose to receive from BLOOM HEALTH.