12 Beauchamp Place

London
SW3 1NQ

Cooltech Consent Form

0207 838 0765.
HBHEALTH.COM

Full name of the patient________________________________________ Birth date ________________

Address _______________________________________________________________________________
City_______________________________________________ Phone no. ___________________________

I HEREBY DECLARE THAT: For the present document I require and give my consent to the
named Practioner__________________________________________.

COOLTECH®. procedure is a cosmetic medicine treatment applied to fat tissue, non‐

invasive, using a controlled cold application system accompanied by suction in the treatment
zone for a period no less than 70 minutes. The fat tissue has a high susceptibility to the
effects of cold, is permanently damaged to being eliminated in a progressive and natural way (lym
phatic), in a process initiated at 15 days from treatment and which can persist till 90 days.

The result of this process is the generalized reduction in the adipose tissue of the treated area.
Patients with the following contraindications should be excluded for the CoolTech® procedure:
Intolerance to Cryotherapy.

 Raynaud disease.
 Hives due to intense cold.
 Cryoglobulinemia.
 Cold fiber hypoproteinemia.
Functional organ failure (serious liver disease. Heart failure, kidney failure, etc.).
Poorly controlled diabetes with secondary diabetes complications.
 Fever.
 Infectious process.
 Chronic infectious processes with associated morbidity (HIV, HCV, etc.).
Pregnancy or breastfeeding.
 Systemic diseases with cutaneous affection: systemic lupus erythematous,
dermatomyositis, scleroderma.
 Active skin lesions in the treatment area.
 Varicose veins, phlebitis and thrombophlebitis.
 Neoplastic.

HB HEALTH of KNIGHTSBRIDGE
12 Beauchamp Place | London | SW3 1NQ
T: +44 (0)20 7838 0765 E: info@hbhealth.com
 12 Beauchamp Place
London
SW3 1NQ
0207 838 0765.
HBHEALTH.COM

PATIENTS RISKS INHERENTS FOR PERSONAL CIRCUMSTANCES:

I DECLARE that the mentioned treatment has been explained to me in the best comprehensive
words, the typical risks that it has, the not desirable effects, the characteristic risks at my person,
and also the discomfort, or sometimes pains that I can feel having a normal post‐treatment. Further
more, it has been informed to me the other options available on the market, and the pros and cons
of each one. Having all the above in mind, the treatment has been chosen by me. I ACCEPT that
RISKS and COMPLICATIONS can happen described by the medical science as inherent in such
treatment.

Between other principal risks, the following side effects have been explained to me:

 Erythema (redness) in the treated area which may last from minutes to a few hours.
Occasional localized bruising may occur associated with the suction process.
Possible paresthesia and dysesthesia (changes in skin sensitivity) in the treated area‐may
last up to 8 weeks.
 Asteniform feeling (fatigue) with the possibility of febrile state lasting less than 24 hours.
Pain during the procedure, mainly during the first 10 minutes, of little intensity.
Pain in the treated area during 7 to 10 days, as well as possible swelling, but not limiting
daily activity.

Exceptional side effect;

 Possibility of fainting, superficial injury associated to the freezing effect.

I UNDERSTAND that the finality of this treatment is to improve my personal appearance having
possibility of some imperfections which may persist. Also, the result may not be what I wanted.
I’m aware that medicine it’s not exact science and nobody can guarantee me absolute
perfection. I’m aware that the result may not be the expected one
by me and I recognize that nobody gave me such guarantee.

I HAVE BEEN INFORMED that number of necessary treatments to get the wished effect has been
explained to me in an indicative way, being impossible to know in advance the numbers of
sessions which are necessary due to the different reaction of each patient.

I COMMIT myself to follow faithfully, at the best of my possibilities, the doctor’s instructions
before,during and after the treatment. I take responsibility in the compliance of the recommended
prescriptions by the Center.

I CERTIFY not to modify or omit my personal information or my medical history and clinic‐
surgical antecedents, specially referred to allergies, illness or personal risks.

HB HEALTH of KNIGHTSBRIDGE
12 Beauchamp Place | London | SW3 1NQ
T: +44 (0)20 7838 0765 E: info@hbhealth.com
 12 Beauchamp Place
London
SW3 1NQ
0207 838 0765.
HBHEALTH.COM

I GIVE MY CONSENT, to take photographs on the treated zone of my body to be used for
Scientific, teaching or medical purposes. I know that my data will be processed automatically,
Which was authorised when they had been explained my rights under the current
OfficialData Protection Act (LOPD).

I was able to answer all my questions about all the above and I fully understand this
consent in every one of its points and signed the document IN ALL PAGES AND DUPLICATE
ratify and consent to treatment is obtained.

I the undersigned have read the above information and hereby give my consent to being treated
for the one of any of the above.

Patient Name _______________________ Patient Signature_______________________

Date of Birth________________________ Date__________________________________

 12 Beauchamp Place
London
SW3 1NQ
0207 838 0765.
HBHEALTH.COM

HB HEALTH of KNIGHTSBRIDGE
12 Beauchamp Place | London | SW3 1NQ
T: +44 (0)20 7838 0765 E: info@hbhealth.com