Customer’s Form

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Customer’s Form

Thank you for visiting us. Please fill out the form below.

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RequiredName
RequiredBirthday	YearMonthDate
RequiredE-mail
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RequiredPlease put a check mark in □ if any of these symptoms/conditions apply to you.	FeverGenerally not feeling wellArrhythmiaPregnantWearing a pacemakerSevere anemiaNone of them is relevant to me
RequiredHave a history of	Bleeding diathesisStrokeActive pulmonary tuberculosisAcrocyanosisThyroid dysfunctionAgammaglobulinemiaCryofibrinogenemiaMyocardial infarction or the recovery period after thatChronic decompensated heart diseaseStage Ⅱ cardiac arrestAny heart diseaseCryoglobulinemiaSystemic vascular inflammation syndromeHysterical neurosisCold intolerance, Cold sensitiveCold feverMalignant tumorStageⅡ,Ⅲ essential hypertension（Blood pressure≧180/100mm）None of them is relevant to me
OptionalWhy did you decide to visit us?

・It is not contradicted for Cryotherapy the presence of any implants(silicon, intraosseous metal rods and plates).
・Please take off all accessories and metals(watch, body pierces) before the session.
・If your skin is wet with drops of water or sweat, wipe it off beforehand.
・If you have cream, lotion or oil on your skin, wipe it off beforehand.
・I was briefed about the risk of low-temperature burns during liquid nitrogen injection and sessions.

03-5775-4555

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