La Luxe Spa

La Luxe Spa Cryolipolysis Intake Form & Cons
Localized High Impact Cryotherapy Services
To enable us to ensure your comfort and safety in all services we provide, please, take time to carefully read this form and answer ALL QUESTIONS to your best ability.
All provided information is CONFIDENTIAL and protected – we will never share it with any 3rd parties, unless required by law.
Introduction. What is localized high impact cryotherapy
For localized cryotherapy services, we use one of the newest and most effective technologies on the market - a device Subzero™ by America Cryo.
The procedure includes spraying the treatment area with dry vapor of carbon dioxide (CO2), as cold as -108° F, under pressure as high as 50 bar, in short 90-second increments. The combination of precise targeting, extremely low temperatures, and strength of the flow result in more rapid and deeper cooling of the affected tissue, producing better results faster.
This technique is not considered a medical treatment, but rapid cooling of the skin and underlying tissue can be used for pain management, stimulation of cell regeneration, tightening and brightening of the skin, anti-aging facials, and reduction of stubborn fat deposits and cellulite.
Thermal shock improves blood flow in the treatment area and helps reduce inflammation. If applied to fat cells that are more sensitive to cold than any other cell in the body, cooling triggers a process called cryolipolysis and results in apoptosis – controlled permanent destruction of subcutaneous fat tissue.
Localized cryotherapy is safe for most people, but some contraindications have been identified and negative side effects are possible. Familiarizing yourself with the below information will help you avoid unwanted consequences.
How many treatments?
For optimum health and wellness, 5 sessions per week for at least two weeks.
For weight loss and metabolic boost, 3-5 sessions per week for at least two weeks (though it should be combined with exercise and healthy eating for maximum effect).
If you have answered 'Yes' to any of the medical conditions above, we advise you to see your doctor first before undergoing treatment with us. We reserve the right to not begin any treatment should we believe that such treatment may cause risk to our client due to the medical conditions which the client has.
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 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.
Localized high impact cryotherapy for pain management
We use a high-pressure flow of gasiform CO2 to lower the tissue temperature in the treated area. The 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.
Liability Waiver
In consideration of using the localized cryotherapy services offered by La Luxe Spa 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 Luxe Spa, 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 Luxe Spa 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 Luxe Spa 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. La Luxe Spa 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 Luxe Spa 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 Luxe Spa personnel.
You accept the responsibility to immediately inform La Luxe Spa 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 Luxe Spa, 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 La Luxe Spa 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 Luxe Spa’s control.
CONSENT
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.
Consent to Use the Clinical Photographs
I am at least 18 years old or older.
I hereby confirm that all information provided by me herein is correct to the best of my knowledge, and I have disclosed all health-related risk factors that I know of. I understand that treatment safety may depend on my health status.
By signing this document, I CONFIRM THAT I HAVE READ, UNDERSTOOD AND AGREED with the treatment-related risks, liability waiver, and provisions of the La Luxe Spa Service Terms and Conditions.
By signing this document, I ALSO CONFIRM THAT I HAVE BEEN EXPLAINED AND AGREE with the choice of consent level related to the use of the “before” and “after” photographs.
I am aware that, to withdraw my earlier given consent that I could do any time without any impact on the services I will be receiving, I must request it in writing.