Cryotherapy Consultation Form

Do you have any of the following?

In or around the intended treatment area:

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 any 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.

We use a high-pressure flow of gasiform CO2 to lower the tissue temperature in the treated area. This 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 La Ritz ​Spa & Salon 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 La Ritz ​Spa & Salon, 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 La Ritz ​Spa & Salon 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 La Ritz ​Spa & Salon if you are feeling sick and have symptoms like fever, congestion, cough, shortness of breath, chest pain, dizziness, nausea, rash, or if you get an acute infection of any kind. The XXX 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 La Ritz ​Spa & Salon staff. Commitment to minimum 5 sessions followed by a proper maintenance protocol is paramount for success. 

You consent to commit to promptly following all safety and other behaviour- and treatment-related instructions posted through the studio or given to you by La Ritz ​Spa & Salon personnel. 

You accept the responsibility to immediately inform XXX 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 you have been explained and understand the administration of the localized high impact cryotherapy services provided by La Ritz ​Spa & Salon, 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 XXX HARMLESS 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 La Ritz ​Spa & Salon 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 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.