Our Online Consultation Form

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First Name

Last Name

Date of Birth *

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Phone *

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Past Medical History *

Please tick the boxes that apply to you.

Aspirin, Warfarin or similar Bleeding Disorders, Easy Bruising or Bleeding

Uncontrolled Blood Pressure

Cardiac Disease Pace Maker, Defibrillator Stent Prosthetic Valves, Surgery

Cancer Benign Or Malignant. Skin or Other

Chronic Pain Syndrome and/or Chronic Fatigue Syndrome

Diabetes Type IDDM +/- Complications

Obesity

Cryoglobulinemia or paroxysmal cold hemoglobinuria. Sensitivity to cold such as cold urticaria or Raynauds disease

Hernia or History of Abdominal, Inguinal or Umbilical Repair

Lymphatic Drainage Disease

Orthopedic, Dental, Surgical Metal Implant. Hips, Knees

Pregnancy and/or Breast Feeding. Menstruation

Obstetric &/or Gynecological Surgery

Psychiatric Illness. Body Dysmorphia - Image Distortion

History of Eating Disorders

Impaired Skin Sensation from Peripheral Vascular Disease, Diabetic Neuropathy or Post Shingles - Zoster Infection

Active Dermatitis, Active Skin Infection, HSV, Shingles - Zoster

Open or Infected Wounds, Recent Wounds-Surgery, Scar Tissue

None of the above