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Todays Date (required)

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Your Name and Surname (required)

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Your Email (required)

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Mobile Number (required)

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Telephone

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Your Age (required)

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Which treatment & areas are you interested in having?

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Treatment Type (required)

Skin TagsWartsVerrucaeSun SpotsPigmentationMiliaCherry Angioma

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Area to be Treated (required)

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Do you have an Immunity Condition or Supressed Immunity?

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Are you currently taking Antihistamines?

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Are you currently taking any other medication?

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Do you suffer from Raynauds Phenomenon?

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Do you have Diabetes?

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Are you pregnant or Breastfeeding?

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CRYOPEN TREATMENT INFORMED CONSENT

To the client:
It is important that you are informed about your skin condition and proposed treatment, including the potential benefits and risks involved.
This disclosure is not meant to scare or alarm you; it is simply an effort to better inform you so that you may give or withhold your consent to the treatment.
CryoPen Therapy is a relatively low-risk treatment and side effects and complications are usually minimal.
Some side effects may occur as a result of the treatment, these include:
• Headaches are not uncommon when freezing on the forehead, scalp and temples and can last for up to 2 hours.
• Pigment changes - both hypo-pigmentation (lightening of the skin) and hyper-pigmentation (darkening of the skin) may occur, both generally last a few months, but can be longer lasting.
• Nerve damage - although rare, damage to nerves is possible, particularly in areas where they lie closer to the surface of the skin, such as the fingers, the wrist and the area behind the ear. This will disappear within several months.
• A blister may appear in the treated area and can last anything from a few hours to a few days, dependent on the area.
• The innovation of CryoPen is the direct application of nitrous oxide under high pressure (55 bar). The high pressure jet may cause minor shards of frozen ice in the air blown away in a circle of approximately 30cm. They will thaw the moment they touch healthy skin.
• Treatments on sites with coarse terminal hair may cause damage to the hair follicles and therefore permanent alopecia is not uncommon.
• Post treatment discomfort like localised swelling, redness and mild tenderness may occur, this usually goes within an hour of treatment.
• Crust formation, or “dirty skin” look is commonly seen for up to 14 days after treatment.

I of the above address, hereby authorise Sunnyside Skin Clinic to treat my benign skin lesion (i.e skin tag, skin wart, brown spot, milia, cherry angioma, verrucae) using the CryoPen for the process of Cryonecrosis.

Please sign to confirm that you have read and understood the following statements. *Please add your initials in each box.

Any concerns that the skin imperfection is anything other than benign, I have cleared and approved by my medical practitioner.

I confirm that I do not Keloid Scar.

I confirm that I am aware of the contra indications relevant to a CryoPen treatment.

I confirm that I have been given the aftercare for treatment with CryoPen and agree to follow the recommendations in order to ensure the best possible results.

I confirm that I have read and been advised of the risk involved in such treatment, the expected benefits of such treatment, and alternative treatment, including no treatment at all.

Sunnyside Skin Clinic may take before and after photos as part of your treatment, Sunnyside Skin Clinic may use these photo’s purely for promotional materials relating to the treatment, please write YES in this box if you give consent for photo’s to be used for these purposes.

I certify that I have read the entire informed consent and I agree to all its provisions. I certify that I have had the opportunity to ask questions and these questions have been answered to my satisfaction.

I fully understand the treatment conditions and procedure.

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Terms and Conditions

We want you to know how our service works and why and how we handle your data. Please state that you have read and agreed to these terms and conditions.

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Contact Permission

Occasionally we would like to newsletters and offers and the latest info from Sunnyside Skin Clinic by Email, post, SMS and other electronic means. We take your privacy very seriously and will only use your personal infomrmation to administer your account and to provide the services you have requested from us. If you consent to us contacting you for this purpose please tick to say how you would like us to contact you.
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