INFORMED CONSENT FORM FOR COLD LIPOLYSIS PROCEDURE

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The purpose of the explanations in this form is not to worry you, but to enlighten you in a scientific framework about the before, during and after of the procedure and its possible risks. Please read carefully. If you have questions or points you do not understand, ask for help.

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1. Personal Information

 

Please fill out this section completely.

 

Name:

Surname:

Date of birth:

Gender:

Mobile number:

Signature:

 

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2. What is Cold Lipolysis Application and for what purpose is it used?

 

Cold lipolysis is the practice of removing excess fat in body parts that are difficult to melt despite diet and exercise, with a cold lipolysis device, without surgical or medical intervention. In cold lipolysis application, a protective membrane is covered on the skin and the area with excess fat is vacuumed with the device head. Following this process, the regional fat tissue is frozen at a temperature between -3 degrees Celsius and -9 degrees Celsius with the device head and the fat tissue is damaged. Since vacuum is applied, only the fat tissue is frozen and the internal organs are not damaged. Since the skin is covered with membranes containing special antifreeze, the skin tissue is also protected from damage. In the cold lipolysis process, frozen fat cells are damaged and disintegrated. This fatty tissue enters the circulation for about 3 months and is used to meet the body's energy needs and is excreted through urine, stool and sweat. Since cold lipolysis is applied to the fat tissue in a specific area, it does not have a weight loss effect. It does not have a tightening effect, it only targets fat tissue. If there is a need for tightening  Tightening procedures can be performed after cold lipolysis. It has a reducing effect on the fat tissue at the application site by 30-60%. It is used to remove excess fat that is difficult to melt despite diet and exercise in the abdomen, side bagels, lower abdomen after cesarean section, hips, inner legs, butt, upper arms, breast area in men and back. The effect of cryolipolysis varies from person to person and in general, less melting of low fat and more melting of excess fat is observed. Before the application and 1 month after the application, you will be informed about your slimness by measuring with a tape measure. Body analysis devices can also show that fat tissue has decreased. To increase the success of cryolipolysis, diet, exercise and drinking plenty of water are recommended. If the recovery after the procedure is appropriate, cold lipolysis can be applied to the same area again after 1 month.

 

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3. What are the points to be considered before cold lipolysis?

 

Please answer the following questions completely.

 

1. Do you have any infection in the application area or in your body?          YES         NO

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2. Do you have a chronic disease such as diabetes?          YES         NO

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3. Do you have an allergy, immune system or rheumatic disease?          YES         NO

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4. Have you had any surgery?          YES         NO

 

5. Do you have an active skin disease or do you have herpes attacks?          YES         NO

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6. Are you prone to bleeding?          YES         NO

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7. Are you positive for hepatitis (HBsAG, HCV) or AIDS (HIV)?          YES         NO

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8. Are you at risk of pregnancy, pregnancy or breastfeeding?           YES         NO

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9. Have you used any medication in the last week?          YES         NO

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10. Have you used blood thinners (aspirin, coumadin, etc.) in the last 3 days?          YES         NO

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11. Have you had any dermatological or aesthetic procedures in the last month?          YES         NO

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12. Do you have cold allergies?         YES         NO

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13. Do you suffer from paroxysmal nocturnal hematuria?         YES         NO

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14. If you have had this procedure done before, have there been any problems?           YES         NO

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WRITE BELOW THE SITUATIONS WHEN YOU ANSWERED YES TO THE QUESTIONS OR WOULD YOU WANT TO EXPLAIN OTHER THAN THE QUESTIONS.

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4. How is Cold Lipolysis Applied and What is the Course of Its Effect?

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• During the cold lipolysis application, a slight pain may be felt at first due to the tension created by the vacuum effect. Later, pain may be felt due to cold application. These pains will disappear after approximately 5 minutes with the effect of cold-related anesthesia. More pain may be felt, especially in some sensitive areas and above-bone areas. If it becomes too disturbing, you need to report it. After the procedure, a manual massage will be performed to disperse the frozen fat tissue and warm the skin. Pain may be felt when this massage begins. As the massage continues, the feeling of pain will disappear. You should not leave our center without massaging the application area.

• Before applying cold lipolysis, the diameter of the application area is measured with a tape measure in three places. 1 month after the procedure, it is measured again with a tape measure in the same places. The thinning will continue for 3 months. While this decrease is greater in places and people with high fat mass, it is less in places and people with low fat mass. Therefore, thinning varies from person to person and region to region.

• Cryolipolysis is performed in a single session and 1 hour is required for each 2 heads. 

• With this application, fat cells are damaged and go to the death process, and it is the only non-surgical procedure that reduces the number of fat cells in the application area.  Since the expansion of the remaining fat cells cannot be prevented, even if the procedure is successful, excess fat may occur again depending on nutrition and lifestyle.

• At least 1 month must pass before cold lipolysis is applied to the same area again, and this period varies from person to person. The headgear can be reattached to different places if desired. After each procedure, you may be told when to come and we can arrange it according to your needs.

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​5. What are the points to be taken into consideration after cold lipolysis?

 

• After the application, it is necessary to drink plenty of water and, if possible, a diet is recommended.

• Heavy exercise is not recommended for the first 3 days after the application.

• The application area should be protected from the sun for 3 weeks and procedures such as solarium should not be performed.

• Our center should be consulted before applying any cosmetic product to the application area.

• If an unexpected effect develops, please contact our center.

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6. What are the Risks and Side Effects of Cold Lipolysis Application?

 

• As with all transactions, there are some risks in this transaction.

• In the application area

  • ​​Redness (erythema) or bruising

  • Local swelling in the application area

  • crusting

  • Frostbite may occur.

  • Numbness (may last up to 1 month)

  • Pain (may last mildly for up to 1 week)

• Darkening or lightening of the skin color may occur in the application area.

• There may be partial increases in cholesterol levels in people who do not consume enough water.

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The side effects mentioned above are unlikely to occur. These side effects generally occur in people with sensitive skin. Besides, they are not permanent. It is recommended to consume plenty of water, but not excessively, to eliminate fats.

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APPROVAL OF THE PERSON TO BE TRADED

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This procedure is not of vital importance like other cosmetic applications. Cosmetic procedures are non-medical interventions performed to reduce the negative effects on your skin such as wrinkles, lines, spots, scars, tattoos, capillaries, hair loss, sagging, stretch marks, unwanted hair, lack of moisture or unpleasant facial and body appearances. For reasons that are not fully understood, the success and permanence of the procedure may be shorter than expected. Additionally, no guarantee can be given regarding the results of the application. Any side effects that may occur will be evaluated by our center and the improvement (prescription adjustment, medical intervention, emergency intervention) procedures will be carried out by our center's contracted doctor in the doctor's office. You can reach us at any time through the communication channels provided to you by our center.

 

• I was explained and understood that no cosmetic intervention, medical intervention or treatment could be performed on me without my permission.

• I have read the text above that contains the information that must be given before COLD LIPOLYSIS application. I understand the expected impact and risks of the method to be applied.

• In addition, other application options, possible consequences and risks were explained to me, written and verbal explanations were made to me about this procedure, necessary warnings were given and I understood it.

• I was in a position to ask questions about the trading options to be applied and their risks. My questions and concerns were discussed and answered to my satisfaction.

• It was stated to me that visual material samples (such as photographs) could be taken before, during and after the procedure in order to evaluate the effectiveness of the procedure to be performed, and I agreed.

• I understand that no guarantee is given as a result of the procedure to be performed on me.

• I did not encounter any coercive behavior in purchasing this application.

• In these conditions, COLD LIPOLYSIS  I voluntarily agree to have it done and to pay the costs required for this application.

 

THE PERSON TO whom the APPLICATION IS MADE

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Name and surname:

History:

Signature:

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THE PERSON WHO MAKES THE APPLICATION

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Name and surname:

History:

Signature:

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THE PERSON WHO WITNESSED THE APPLICATION

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Name and surname:

History:

Signature:

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