1324 Princess St
Kingston, ON K7M 3E2
Website: www.ucosmetic.com
Email: nuyu@ucosmetic.com
Phone: 613-536-LASR (5277)
Fax: 613-536-5108
Dr. Kim Meathrel, MD, FRCSC, Plastic Surgeon, Associate Professor of Surgery, Queen’s University
Dr. Caroline Sangers, MD, CCFP, Cosmetic Medicine, Family Practice, Emergency Medicine
CoolSculpting®
Non-Invasive Body Contouring
CONSENT FORM
Please read and initial each statement.
I have read the Coolsculpting® Non-Invasive Body Contouring Information and
Treatment Instructions Sheet and have had an opportunity to ask questions about
the treatment and I am satisfied with the answers.
The cost of treatment has been discussed with me and I agree to pay this amount.
U Cosmetic does not give refunds for treatments. Quotes for treatment done at
consultation are valid for three months from the date of the consultation.
I authorize the laser technician to perform Coolsculpting® treatments on me.
I understand:

there may be side effects of Coolsculpting® treatments as listed in the
information sheet that include redness, tenderness, bruising, swelling,
numbness, deep itching, cramping or diarrhea which can last for a few
days to a few weeks. Rare side effects include skin burn, permanent
swelling, hardness or skin colour changes, nodule or hernia formation
and extremely rarely late onset severe pain. There may be risks not yet
known at this time.

Coolsculpting® treatments cannot stop fat cells from storing more fat if
excess calories are consumed or new cellulite from forming. Coolsculpting®
cannot prevent natural aging changes. Some people exceed our expectations
and
some
people
respond
below
expectations.
A
full
Treatment2Transformation® series is recommended for your best results.
Results vary between individuals.
Some people exceed our
expectations and some people respond below expectations. Although
good results are expected, with the focus on improvement and not
perfection, every person is unique and it is impossible to guarantee
results.

maximum results occur two to four months after treatment.
May 2015
Coolsculpting® Treatment (CONSENT)
1

and have reviewed the medical conditions that are listed in the
Coolsculpting® information sheet and confirm that I do not have any of these
conditions. I have given a complete list of my medications.

there are other options for treatment such as radiofrequency, liposuction or
other surgical treatments and include not having the procedure.
I authorize the taking of clinical photographs for:

my clinic record

research and education (discretion applied)

publication

the U Cosmetic website (discretion applied)

the U Cosmetic Brag Book kept in the clinic (discretion applied)
I have read and understand this Coolsculpting® Non-Invasive Body Contouring Treatment
Consent Form. I have had an opportunity to ask questions and all of my questions have been
answered satisfactorily. I accept the risks and complications of the procedure.
Patient name (please print)
Date
Signature
Witness name (please print)
Date
Signature
May 2015
Coolsculpting® Treatment (CONSENT)
2