Geneo Consent Form Geneo Consent Form Client's Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Clinician's Name(Required) First Last Date of Service(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 HandpiecesPregnant or Nursing?(Required) Yes No Coagulopathies, vascular or bleeding disorders, telangiectasia, varicose veins, thrombosis, phlebitis in the treatment area?(Required) Yes No Current history of skin cancer, neoplastic tissue pre-malignant moles, cyst, abscesses or other?(Required) Yes No Known allergies to cosmetics, products or experience allergic reactions like hives?(Required) Yes No Using Accutane or retinal products?(Required) Yes No Last use of above 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) Yes No Last date of the above cosmetic procedures(Required) MM slash DD slash YYYY Severe Concurrent disease such as un-controlled diabetes, nervous diseases, or cardiac disorder?(Required) Yes No List all skin care products or over the counter medications.UltrasoundUnder the age of 18 years old?(Required) Yes No Metal implants in treatment area (not including dental implants or fillings)(Required) Yes No Pacemaker, internal defribrillator, implanted Neurostimulators or any other internal eclectic system?(Required) Yes No History of skin disorders, keloid scarring, abnormal wound healing, or very dry skin?(Required) Yes No Impaired immune system due to Immunosuppressive disease suvh as AIDS or HIV or use of immunosuppressive medication?(Required) Yes No OxyGeneoFresh tan within the last 3 days?(Required) Yes No Active eczema rash, fragile skin, swollen, rosacea, dermatitis, psoriasis, herpes simplex, or burnt skin?(Required) Yes No Consent(Required) I agree to all of the followingI 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) Yes No Client Signature(Required)Date of Birth(Required) MM slash DD slash YYYY Daljeet Arora2022-09-28T18:16:49+00:00
