Child Data Pre Appointment Berkhamsted

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Lipo Sculpt Child Data Pre Appointment Berkhamsted

Welcome! This form is for parents who have already spoken with a consultant to schedule their child’s appointment.

Please fill out the fields below to confirm the details. We’ll be in touch if we have any questions.

Child Data form Pre Appointment

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Child Name*

Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Address*

Contact Number (Parent/Guardian)*

Email Address (Parent/Guardian)*

Parent / Guardian Details

Full Name*

Relationship to Child*

Treatment Information

CryoPen treatment involves the use of extremely cold temperatures to remove benign skin lesions such as warts, skin tags, milia, or other superficial blemishes. This procedure may cause mild discomfort, redness, or blistering as the treated area heals.

Areas to be treated*

Face

Neck

Hands

Other

Other Area to be treated*

Description of lesion(s)*

Medical History (Child)

Please tick any that apply:*

Asthma

Eczema / Sensitive Skin

Cold sores

Diabetes

Circulatory problems

Keloid (raised) scarring tendency

Allergies (please list)

Other medical conditions

Current medications

Allergies*

Other Medical Conditions*

Current Medications*

Consent & Acknowledgement

I, the undersigned parent/legal guardian, understand that:
• CryoPen treatment uses controlled freezing to remove benign skin lesions.
• The practitioner will assess suitability before proceeding.
• Results are not guaranteed and more than one session may be required.
• Temporary side effects (e.g., redness, blistering, pigmentation changes) can occur.
• I will follow all aftercare advice provided.

I give consent for photographs (optional, for clinical records only)

Yes

No

I confirm that I am the parent/legal guardian of the child named above and give permission for CryoPen blemish removal treatment to be carried out.

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