Lavender Falls Face & Body Spa LLC

Client Informed Consent Form






19239 Stone Oak Pkwy, #201

San Antonio, Texas 78258

Phone: 210-446-0903

Online Booking Available

Treatment Consists of:

CryoClear works by spraying Carbon Dioxide onto the skin for 5-10 seconds. CryoClear freezes at – 79° C to a depth that freezes only the epidermal layer, delivering a very safe and clinically effective treatment.

CryoClear’s high efficacy – over 95% – combined with less destruction of healthy tissue makes it perfect for treating age spots, sun spots and skin tags.

Clients Acknolwledgements:

Clients with undiagnosed skin lesions; Melanoma; Previous sensitivity or adverse reaction to cryosurgery or cryo-treatments.  Active bacterial or fungal infections. Active inflammation of the treatment area. May not want to have this treatment performed.


Information: I acknowledge I am not currently nor have used any of the products listed below within the time frame listed.

Pre-Treatment Acknowledgement

     Accutane or Retinol with the last year

     Sunburn or Sun Exposure- 1 week prior to treatment.


     Botox/Dysport/Xeomin within the last week.

     Dermal Fillers within the last two weeks.


*Notify your aesthetician of any medical conditions & medications (Current & within the last 90 days).

Post Treatment Acknowledgement

     Following treatment, you may experience some tingling and redness.


CryoClear causes the lesion to go through 4 stages before the final result. 

      First, the treated lesion will become red

      Second phase, the lesion darkens

      Third phase causes the lesion to darken and fall off to reveal new pink healthy skin.

      The final phase allows skin cell turnover to gradually grow over the 28 day process.

Post Treatment Instructions

      Do not pick or scratch the treated area

      Bathe as normal

      Apply fragrance free moisturizer 1-2 times per day for 7 days after treatment

      Limit sun exposure for 7 days and wear at least SPF 50 on the lesion

Side Effects:

Possible side effects include but are not limited to:

• Following treatment you may experience mild discomfort, erythema or loss of pigmentation at the treatment site.

• Blistering of treatment area may occur within a few hours (clear, red or purple),

• Bleeding may occur (though this is not common).

• A white mark (hypopigmentation) or scar may result.

• Scarring and textural changes are also rare side effects but can result from this procedure.

There may be risks not yet known at this time.


      I understand that any time the skin barrier is compromised; there is a small risk of infection. I will contact my aesthetician immediately should this happen.

      The CryoClear treatment has been fully explained and any questions or concerns that I have, have been addressed.

       I acknowledge that no guarantee has been given to me as to the condition of the complexion, skin pore size, wrinkles or the percentage of improvement expected following treatment, due to each individual’s unique reactions.

      I acknowledge this procedure is strictly an elective cosmetic procedure and that no medical claims have been expressed or implied.

       Photographs May be taken for comparison for future treatments for my chart.


I have read the above and understand it. My provider has answered my questions satisfactorily. I accept the possible risks and complications of the treatment.


I acknowledge that Lavender Falls Face and Body Spa has a no-refund policy on any products or service. There will be no refunds for any reason.


All services performed are without any guarantee. By continuing with service, you are confirming that you have read and understand our no refunds policy.






Lavender Falls Face and Body Spa LLC

Thank you for choosing and trusting Lavender Falls Face & Body Spa LLC for your aesthetic needs

Feel free to contact us at 210-446-0903 if you have any questions




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Signature Certificate
Document name: Cryo-Clear
lock iconUnique Document ID: 6a35f08528cce2f0243ae9c50c6498a0bf224a15
Timestamp Audit
April 8, 2017 8:05 pm CSTCryo-Clear Uploaded by Lavender Falls Face and Body Spa LLC. - IP