CryoClear® Consent & Release

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Patient Information

Patient Name*

CryoClear® Consent & Release

Clinic address: 5760 West 120th Avenue, Suite 220, Broomfield, CO 80020

For the Client:

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 begin treatments.

I, at the address shown above, have requested treatment using CryoClear on sun spots, age spots and/or skin tags. I understand that the practice of aesthetic medicine is not a precise science 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. Each treatment 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 the treated skin slowly falling off and new skin appearing in its place. Occasionally following treatment you may experience mild discomfort, erythema or loss of pigmentation at the treatment site.

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.

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