21 East 1st Street, New York
+1 212-228-5909
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Intake Form
Tell us a little bit more about yourself so we can bring you the best service!
Basic Information
Name
First
Last
Date of Birth
MM slash DD slash YYYY
Email
Phone
Have you ever tried any other aesthetic procedures in the past?
Yes
No
If “yes”, which ones?
How did you hear about Cryoskin?
Friend/Family
TV/Radio
Internet
Other
Background Information (please check all that apply)
Botox in the past 30 days
Fillers in the past 90 days
Surgery in the past 6 months
Implants in desired treatment area Pregnant and/or breastfeeding Active/Past Cancer
Kidney and/or Liver disease Cardiovascular Disease
Lymphatic disorders
Uncontrolled Diabetes
Severe allergy to cold
Severe Raynaud’s Syndrome Eczema, rashes, or dermatitis
Open or infected wounds
Circulatory disorders Pacemaker/metal implants
Mesh inserts
Incision scar(s) in the desired area HIV/AIDS
Body piercings in the desired area Using topical antibiotics
Lower Limb Ischemia
Cold-related Illness
Progressive diseases (MS, ALS, etc.)
Bacterial/viral skin infection
Wound healing disorders
Impaired skin sensation
Known sensitivity to propylene glycol
Hernia in desired treatment area
Preferred Targeted Areas
Please check all that apply
Face
Chin
Neck
Chest
Arms
Abdomen
Love Handles
Back Area
Butt
Under Butt Area
Thighs
Inner Thighs
Hips
Knees
Calves
Ankles
Lifestyle Information
How many times per week do you exercise?
How much water do you drink per day?
How would you rate your diet?
Extremely healthy
Generally healthy
Needs improvement
What is your goal with Cryoskin?
Do you have any questions about Cryoskin?
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