OxyGeneo Consult

You are being treated with the Geneo platform for anti-aging and/or skin brightening treatments. The platform works with OxyGeneo Technology.

Special gel will be applied on your face and the treatment will be performed using an applicator with a disposable capsule attached to it.

During the treatment the reaction between the capsule and the gel will cause the infusion of the active ingredients.

The treatment is none invasive, pleasant and does not require down time.

Contact Info*

First NameLast Name

Address*

Street Address

CityProvince

E-mail*

Email Address

Phone Number*

Area CodePhone Number

How did you hear about us?

Have you had an OxyGeneo Super Facial before?*

YesNo

What are your specific skincare concerns?*

What skincare products are you currently using at home?*

Brand(s):

Have you ever had a reaction to skincare products/ingredients?*

YesNo

Please provide details:

Existing or Recent Illness:*

YesNo

Please provide details

Hospitalization/Surgery:*

YesNo

Please provide details

Medication:*

YesNo

Please provide details

Aesthetic procedures in the treatment area:*

YesNo

Please provide details

Allergies (including to cosmetic procedures):*

YesNo

Please provide details

Do any of the following apply to you? (Please indicate if any)

Under 18 years of agePregnant/NursingCurrent or history of cancer, especially skin cancer, or pre-malignant moles.Any active condition in the treatment area, such as sores, hemorrhages or risk of hemorrhages, septic conditions, psoriasis, eczema and rash as well as irritated or damaged skin due to excessive fresh tanning.Vascular disorders such as: un-controlled diabetes, nervous diseases, cardiac disorder and cancer. In such cases, consult the treating physician.Any aesthetic procedure done recently within applied area or recent use of products such as Accutane or Retin A, consult the treating physician before using Geneo.

Photographic Consent & Release*

I give permission for my photos to be used for advertising.I give permission for my photos to be used on the website.At my request, my identity will remain anonymous.At my request, my photos will only be used for my chart.At my request, no photos will be taken.

Treatment Agreement

I, the client, agree to inform of all changes in my physical condition.

I agree to undergo the treatment, as detailed below in this document. I was explained and understand the results, the reactions and the course of the treatment.

I confirm that I do not suffer from any of the above described conditions.

I have had the opportunity to consider the following information, ask questions and have had these answered satisfactorily.

Client Consent

I understand that receiving the treatment is my choice and that I am free to withdraw at any time, without giving any reason.

I was told about the possible side effects of the treatment including: local pain, excessive skin redness (erythema), excessive swelling (edema), damage to the natural skin texture (crust, blister, and burn), excessive tingling sensation, fragile skin and bruising. Although these effects are rare and expected to be temporary, any adverse reaction should be reported immediately.

By signing below, I confirm that I have read and understand the above information and agree to undergo the treatment.

Client Signature*

Clear

Date

OxyGeneo Consult Form