First and Last Name
Date of Birth
Have you ever tried any other aesthetic procedures in the past?
If "yes", which ones?
How did you hear about Cryoskin?
Background Information (check all that apply)
Botox in the past 30 days
Surgery in the past 6 months
Pregnant and/or breastfeeding
Severe allergy to cold
Fillers in the past 90 days
Severe Raynaud's Syndrome
Eczema, rashes, or dermatitis
Open or infected wounds
Incision scar(s) in desired area
Body piercings in the desired area
Using topical antibiotics
Progressive diseases (MS, ALS, etc.)
How many times per week to you exercise?
How much water do you drink per day?
How would you rate your diet?
How many sessions do you want?
1 Session Facials are $250 Body is $350
3 Sessions of body 975 saving $75
5 Sessions Facial $995 Saving $225
5 Sessions Body $1500 Saving $250
10 Sessions Body $2750 Saving $750
10 Sessions Facial $1500 Saving $1000
Do you have questions about Cryoskin
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