Cryo-Lip Web Order Form

(to be completed by requesting clinician)


Patient Details

if known, enter the Cryo-Lip ID code in this format (123/456/7890)

* Surname
* Name
* Date of Birth
ID code



Product Details

SVF is shipped in 5 ml vials at room temperature and ready for re-injection. Each vial has its own Data Sheet containing the details of various quality control tests including quantity, viability, identification and sterility of the cellular mixture. One vial contains enough ASCs to  be used for one treatment session, for example for facial rejuvenation.  



PLA is shipped in specialized transport bags, each containing up to 500ml of PLA. The volume of PLA delivered will depend on the actual volume stored. As a rule, PLA is stored in separate bags of 100 ml each.

The release tissue has its own Data Sheet with relevant Quality Control results including quality, viability, identification and sterility.


Please indicate the request release below:



requested SVF tubes
Requested PLA
amount of PLA (in ml)



Doctor's Details

* Surname
* Name
* E-mail


Delivery Details

The vial will be delivered by courier on the morning of the date of the planned procedure. It is important to re-inject it on the same day.

NOTE : Allow at least 1 week beween ordering and the procedure. Deliveries on Mondays are not yet possible.


* Delivery Date  
* Clinic Name
* Address
* Postal Code
* Town
* Telephone



Please click on the submit button below to confirm your order. By clicking here:




You will receive an acceptance email within 2 business days, confirming the delivery date and invoicing details. In case you don't receive such an email, please contact 

Dr Peter De Waele 

T: +31 575 50 91 00
F: +31 575 54 74 24
M: +32 475 96 46 93