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This form, together, with the general information sheet, is designed to provide with information for making an informed decision regarding your treatment with the GeneO+ platform. If you have any questions, please do not hesitate to ask.

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.

December 13, 2018

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

Cancellation Policy:
Please give us a 4 hour notice or you will be charged a $25 no-show fee.

Please initial that you have read the text above


First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Second Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Third Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Do you smoke?*
No
Yes
Are you pregnant?*
No
Yes
Have you ever had cosmetic surgery?*
No
Yes
Click to customize question*
No
Yes

If you have had cosmetic surgery when did you have it? Define the procedures.

Are you taking any medication? If so what kinds?

Any health problems? If yes, explain:

Any allergic reactions to medication? If yes, describe:

Do you have any allergies?
Do you suntan?*
No
Yes
Do you use sunscreen?*
No
Yes

Please name the brand of products you are currently using: Cleanser,Toner, Moisturizer,Scrub, Mask,Buff Puff, Other

Have you ever used Retin-A? If yes, what strength?
Have you ever been treated with Phenol or Trichloracetic acid?*
No
Yes
Have you ever used Hydroquinone (skin lightener)?*
No
Yes

Have you ever been on Accutane? If yes, when?
Have you ever had herpes, hives, cold sores, fever blisters, keloids? Check all that apply:
Herpes
Hives
Cold Sores
Fever Blisters
Keliods

If yes to above when?
How would you characterize your skin: (circle one) Sensitive Rough Dry Oily/Acne-prone*
Sensitive
Rough
Dry
Oily/Acne-Prone

If you had one complaint about your skin, what would it be? *

Describe your skin in three words: *

Additional comments/concerns:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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