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Client Details

Client Name *

Date of Birth *

Phone Number *

Email Address *

Treatment Date *

Practitioner / Witness Name *

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Consent Version

Consent Version: ELURENA-CONSENT-FAT-FREEZING-V1.0-2026

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ELURENA – FAT FREEZING CONSENT & LIABILITY FORM

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Elurena Fat Freezing is a non-surgical treatment that uses controlled cooling to target and reduce fat cells. It is not a weight-loss solution and results vary per person.

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What to Expect

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During or after Fat Freezing treatment, you may experience:

Temporary sensations may include pulling, tingling, aching, cramping, or numbness.Redness, swelling, bruising, or tenderness may last days to weeks.Results may appear in 3–12 weeks and may require multiple sessions.Rare risks may include skin changes, hardness, nodules, freeze burn, hernia, or enlargement of the treated area.No refunds are offered for treatments.

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Fat Freezing Contraindications

Do you have cold-related conditions such as Raynaud’s disease, cold urticaria, or cryoglobulinemia? *

Yes No

Do you have poor circulation, neuropathy, or impaired sensation? *

Yes No

Do you have open wounds, recent surgery, scar tissue, or hernia in or near the treatment area? *

Yes No

Do you have bleeding disorders or use blood thinners? *

Yes No

Are you pregnant or breastfeeding? *

Yes No

Do you have a pacemaker or implanted medical device? *

Yes No

Do you have active skin conditions such as eczema, dermatitis, rashes, or similar conditions? *

Yes No

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General Medical Declaration

Have you disclosed your full and accurate medical history to the practitioner? *

Yes No

Are you currently taking any medication that may affect treatment safety? *

Yes No

Have you had any recent cosmetic, medical, or aesthetic procedures in the treatment area? *

Yes No

Do you understand that treatment may be refused or postponed if there is a safety concern? *

Yes No

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Fat Freezing Consent Confirmation

Fat Freezing Consent Confirmation *

I understand the Fat Freezing treatment, possible risks, contraindications, and limitations. I understand that results are not guaranteed and that multiple sessions may be required. I confirm that I have disclosed my full medical history and give consent to proceed with Fat Freezing treatment.

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Optional Photography Consent

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I authorize Elurena and its staff to take photographs of me for documenting treatment progress and results, training, education, and marketing use. I understand my name will not be used, my face will not be shown unless I give specific permission, and I may revoke this consent in writing at any time.

Photography Progress Consent

I consent to photographs being taken for treatment progress documentation only.

Photography Training Consent

I consent to photographs being used for training and education.

Photography Marketing Consent

I consent to photographs being used for marketing, digital, print, or online purposes.

Photography Face Consent

I specifically consent to my face being shown, if required.

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Final Treatment Agreement

Treatment Information Confirmation *

I confirm that I have read and understood the Fat Freezing treatment information shown in this form.

Risks and Limitations Confirmation *

I confirm that I understand the possible risks, side effects, contraindications, and limitations of Fat Freezing treatment.

No Guaranteed Results Confirmation *

I understand that treatment results vary and are not guaranteed.

Multiple Sessions Confirmation *

I understand that more than one session may be required.

No Refunds Confirmation *

I understand that no refunds are offered for completed treatments.

Questions Confirmation *

I confirm that I have had the opportunity to ask questions before proceeding.

Consent to Proceed *

I consent to proceed with Fat Freezing treatment.

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Signature

Client Signature *

Client Signature Date *

Practitioner / Witness Signature *

Practitioner / Witness Signature Date *

ELURENA – Fat Freezing Treatment Consent Form

Client Details

Consent Version

ELURENA – FAT FREEZING CONSENT & LIABILITY FORM

What to Expect

Fat Freezing Contraindications

General Medical Declaration

Fat Freezing Consent Confirmation

Optional Photography Consent

Final Treatment Agreement

Signature