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info@anewspa.com #251-278-2639
info@anewspa.com #251-278-2639
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Geneo Consent Form

Geneo Consent Form

Client's Name(Required)
MM slash DD slash YYYY
Clinician's Name(Required)
MM slash DD slash YYYY
This form is designed to provide you with information on making an informed decision regarding your treatment using the GENEO system. If you have any questions, please do not hesitate to ask a member of our staff.

All Handpieces

Pregnant or Nursing?(Required)
Coagulopathies, vascular or bleeding disorders, telangiectasia, varicose veins, thrombosis, phlebitis in the treatment area?(Required)
Current history of skin cancer, neoplastic tissue pre-malignant moles, cyst, abscesses or other?(Required)
Known allergies to cosmetics, products or experience allergic reactions like hives?(Required)
Using Accutane or retinal products?(Required)
MM slash DD slash YYYY
Any aesthetics, ablative, surgical, invasive procedure (platic/cosmetic surgery), skin resurfacing, chemical preel, dermabrasion, and fillers or botox?(Required)
MM slash DD slash YYYY
Severe Concurrent disease such as un-controlled diabetes, nervous diseases, or cardiac disorder?(Required)

Ultrasound

Under the age of 18 years old?(Required)
Metal implants in treatment area (not including dental implants or fillings)(Required)
Pacemaker, internal defribrillator, implanted Neurostimulators or any other internal eclectic system?(Required)
History of skin disorders, keloid scarring, abnormal wound healing, or very dry skin?(Required)
Impaired immune system due to Immunosuppressive disease suvh as AIDS or HIV or use of immunosuppressive medication?(Required)

OxyGeneo

Fresh tan within the last 3 days?(Required)
Active eczema rash, fragile skin, swollen, rosacea, dermatitis, psoriasis, herpes simplex, or burnt skin?(Required)
Consent(Required)
I understand there may be some degree of minor discomfort, i.e., scratches or itchiness.

I understand there are no guarantees to this procedure.

I understand that to achieve maximum results, I will need several ongoing treatments and will need to use a daily product over a period of time.

I understand that the possibility of irritation and redness ecists and that I should notify my skin care professional when irritation persists.

I will follow the home care program specifically designed for me without changing or adding products without consulting with my skin care professional. I will have this treatment performed on me will follow all prescribed directions above.

I have read the pre and post instruction sheet and agree to all the above.

My questions have been answered by the staff to my complete satisfaction. I accept the risks and complications of the procedure.
I agree to have my before and after photo(s) released to my provider and Geneo?(Required)
MM slash DD slash YYYY
Daljeet Arora2022-09-28T18:16:49+00:00

Book your Appointment Today:
251-278-ANEW (2639)

Hours of Operation:
Monday-Friday: 10-7
Saturday: 10-2
Sunday: Closed

2004 US Highway 98, Suite C,
Daphne, AL 36526

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