Prior to receiving this treatment, I have been candid in revealing any condition that may have a bearing on this procedure, such as: • Pregnancy • History of skin cancer or pre-malignant moles • Excessive fresh skin tan (within the last few days) • Any active conditions in the treatment area, such as: sores, eczema, rash, fragile skin, swollen, burnt or injured skin, active acne, rosacea, dermatitis, psoriasis, or active Herpes Simplex • Vascular disorders such as: telangiectasia, varicose veins, thrombosis, phlebitis in the applied area • Severe concurrent disease such as: un-controlled diabetes, nervous diseases, cardiac disorder and cancer • Any aesthetic, ablative, surgical, invasive procedure performed recently on the applied area such as plastic or cosmetic surgery, skin resurfacing, deep chemical peels, deep dermabrasion, injected chemical or bio-material substances or fillers, and Botox • Recent use of products such as Accutane or RetinA • Known allergies to cosmetics or other products, or experienced severe allergic reactions like hives I understand there may be some degree of minor discomfort, i.e., scratchiness, 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 exists 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 any products without consulting with my skin care professional. I have read the enclosed consultation and understand the contents. I agree to all of the above to have this treatment performed on me and will follow all prescribed directions regarding post peel care. My questions have been answered by the staff to my complete satisfaction. I accept the risks and complications of the procedure.
February 18, 2019
Contraindications Current or history of skin cancer, or pre-malignant moles Pregnancy or nursing Any active conditions in the treatment area, such as sores, eczema, rash, fragile skin, swollen, burnt or injured skin, active acne, rosacea, dermatitis, psoriasis, or active Herpes Simples Take precaution when treating over areas of active acne, avoid areas of severe active acne. When treating patients with predisposition to acne, occasional and transit acne eruptions may occur, which should be cared with acne treatment products Excessive fresh skin tan (within the last few days) Vascular disorders such as: telangiectasia, varicose veins, thrombosis, phlebitis in the applied area Severe concurrent disease such as: un-controlled diabetes, nervous diseases, cardiac disorder and cancer. In such cases, consult the treating physician In case of any aesthetic procedure performed recently on applied area such as mesotherapy, peeling, resurfacing or recent use of products such as Accutane or RetinA, consult the treating physician before using geneO+ Known allergies to cosmetics or other products, or experienced severe allergic reactions like hives Precautions Precautions should be taken when considering treatment after other aesthetic procedures. It is recommended to consult with the treating aesthetic physician. Use caution in the following: Any surgical, invasive, ablative procedure in the treatment area within three months prior to treatment or before complete healing Face lift, eyelid surgery, skin resurfacing, deep chemical peeling or deep dermabrasion in the treatment area within three months prior to treatment or before complete healing Injected chemical substance, threads, synthetic fillers in the treated area-treat only upon approval and responsibility from treating aesthetic physician Fillers, collagen, fat injections or other injected bio-material in the treated area within two-three weeks prior to treatment and not before complete healing has occurred Botox in the treated area within 2 weeks prior to treatment and not before complete healing has occurred ULTRASOUND CONTRAINDICATIONS • Under 18 years of age • Pacemaker or internal defibrillator, implanted neurostimulators or any other internal electric system • Metal implants in the treatment area (not including dental implants and fillings) • Pregnancy or nursing • Current or history of cancer, especially skin cancer, or pre-malignant moles, neoplastic tissue or space occupying lesions (malignant or benign such as: cysts, abscesses, hematoma) • Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications • Sever concurrent conditions such as cardiac disorders, epilepsy or lupu. • Poorly controlled endocrine disorders, such as diabetes • Bleeding disorders, coagulopathies, areas of thrombophlebitis, or use of anticoagulants • Any active condition in the treatment area, such as sores, hemorrhages or risk of hemorrhages, septic conditions, psoriasis, eczema and rash as well as excessively/freshly tanned skin • History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin • Any surgical, invasive, ablative procedure in the treatment area before complete healing • As per practitioner’s discretion, refrain from treating any condition which might make it unsafe for the patient Precautions Precautions should be taken when considering treatment after other aesthetic procedures. It is recommended to consult with the treating aesthetic physician. Should you choose to perform OxyGeneo treatment, use caution in the following: • Patients taking medications, herbal preparations, food supplements or vitamins that might cause fragile skin or impaired skin healing such as prolonged steroid regime, Isotretinoin (Accutane), tetracyclines, or St. John's Wort • Patients having any medical condition that might impair skin healing • Aesthetic procedures in the treatment area, such as: fillers, gold/plastic threads, fat implants • Patients undergoing frequent skin resurfacing or chemical peelings or other aesthetic procedures that may cause sensitive, fragile or thin skin • Patients having predisposition to excessive allergic reactions such as hives, shortness of breath etc. • Patients having areas of reduced sensations or circulation or over anesthetized areas or over bony areas. NOTE: In case of uncertainty regarding potential side effects, have the patients consult their physician and bring consent for treatment. SIDE EFFECTS: Improper use of the System could result in possible side effects. Although these effects are rare and expected to be temporary, any adverse reactions should be reported to a physician immediately. Side effects may appear either at the time of treatment or shortly after. • Pain • Excessive skin redness (Erythema) • Damage to natural skin texture (crust, blister, burn) • Excessive Swelling (Edema) • Fragile skin • Bruising • Itching
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