FOR PRACTICE USE ONLY - NOT FOR DISTRIBUTION

TREATMENT RECORD FORM

Patient Name:
Patient ID/No:

TREATMENT SESSION # Date: Weight: Led by:

☐Pre-treatment photos taken Start time: End time:

Applicator Placement
☐CoolMini® Applicator

CoolAdvantage™ Applicator: CoolAdvantage Petite™ Applicator:

 CoolCurve+ Advantage™ Contour  CoolAdvantage Petite Curve Contour
 CoolCore Advantage Contour ™  CoolAdvantage Petite Flat Contour
 CoolFit Advantage Contour ™

CoolAdvantage Plus™ Applicator:

 CoolCurve+ Advantage Plus Contour
 CoolCore Advantage Plus Contour

☐CoolSmooth™/CoolSmooth PRO™ Applicator vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolCurve+™ Applicator vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolCore Applicator
™
vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolFit Applicator
™
vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolMax Applicator
™
vacuum settings: ☐ 60-75-60 ☐__________________

Treatment comments/observations: ☐2-minute post-treatment massage

Follow up comments/observations: Date: Weight: Led by:

☐Post-treatment photos taken
☐48-hour post-treatment phone call

TREATMENT SESSION # Date: Weight: Led by:

☐Pre-treatment photos taken Start time: End time:

Applicator Placement
☐CoolMini® Applicator

CoolAdvantage™ Applicator: CoolAdvantage Petite™ Applicator:

 CoolCurve+ Advantage Contour ™  CoolAdvantage Petite Curve Contour
 CoolCore Advantage Contour ™  CoolAdvantage Petite Flat Contour
 CoolFit Advantage Contour ™ 

CoolAdvantage Plus™ Applicator:

 CoolCurve+ Advantage Plus Contour
 CoolCore Advantage Plus Contour

☐CoolSmooth™/CoolSmooth PRO™ Applicator vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolCurve+ Applicator™
vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolCore Applicator
™
vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolFit Applicator
™
vacuum settings: ☐ 60-75-60 ☐__________________

☐CoolMax Applicator
™
vacuum settings: ☐ 60-75-60 ☐__________________

Treatment comments/observations: ☐2-minute post-treatment massage

Follow up comments/observations: Date: Weight: Led by:

☐Post-treatment photos taken
☐48-hour post-treatment phone call
In the U.S., the CoolSculpting procedure is FDA-cleared for the treatment of visible fat
bulges in the submental area, thigh, abdomen and flank, along with bra fat, back fat,
underneath the buttocks (also known as banana roll) and upper arm. In Taiwan, the CoolSculpting procedure is cleared for the breakdown of fat in the flank (love handle), abdomen, and thigh. Outside the U.S. and Taiwan, the CoolSculpting procedure for non-invasive fat reduction is available
worldwide. ZELTIQ, CoolSculpting, the CoolSculpting logo, the Snowflake design, and CoolMini are registered trademarks, and CoolCore, CoolCore Advantage, CoolAdvantage Petite, CoolCurve+, CoolCurve+ Advantage, CoolFit, CoolFit Advantage, CoolMax, CoolSmooth, and CoolSmoothPRO are
trademarks of ZELTIQ Aesthetics, Inc. © 2017. All rights reserved. IC1372-I