Consent Form for Glo2Facial, Preime Dermafacial, Peptide Firming, Enzymes and Oxygen Rx

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, Oxygen RX by Circadia, Peptides /Enzymes Treatments by Circadia. If you have any questions, please do not

hesitate to ask a member of our staff.

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.

Contraindications

• 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

NOTE: In case of uncertainty regarding potential side effects, have the patients consult their physician and

bring consent for treatment.

Authorization

• I confirm that all information given in this form is true, complete, and accurate and will not hold Medical Aesthetics Bar responsible for anything that they were not aware of due to my lack of information.

  
  

• I acknowledge that no assurance was offered about the outcome.

• I agree to avoid direct sun exposure for 48 hours

• I agree to avoid exercise in the first 12 hours

• I do not have active cold sores

• I have not taken Accutane in the past year

• I agree not to wax for 7 days pre/post treatment

• I agree not to use retinol products for 5 days pre/post treatment

• I understand the possible allergic reaction notification

• I agree to notify esthetician of any concerns

• I agree to apply SPF following the treatment and each day to protect my skin

*****I must notify prior to my treatment any of the followings:

Face lift, eyelid surgery, skin resurfacing, deep chemical peeling, Injected chemical substance, threads, synthetic fillers or deep dermabrasion

Fillers, collagen, fat injections or other injected bio-material

Botox in the treated area within 4 weeks prior to treatment and not before complete healing has occurred.******** appointments must be schedule at least 4 weeks after.

I hereby consent to and authorize Medical Aesthetics Bar to perform a facial treatment on myself. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. Therefore I release the Licensed Esthetician and

Medical Aesthetics Bar from any and all claims, liabilities, damages, actions, or causes of action arising from the facial treatment received hereunder, including, without limitation, any damages arising from acts of active or passive negligence on the part of the Esthetician, to the fullest extent allowed by law. I also recognize that there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an

additional cost. If my Esthetician provides me with post-treatment home care instructions or suggest certain facial products, I understand the

importance of following their specific instructions. In the event that I have any questions or concerns, I will consult the Esthetician immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history. Including all known allergies or prescription drugs or

products I am currently ingesting or using topically. I have read and fully understand this agreement and all information detailed above. I

understand the facial treatment and accept the risk. If I have any questions, I will ask the Esthetician before I receive any treatment. I accept

the terms of this agreement and will not hold the Esthetician or Medical Aesthetics Bar responsible for any of my conditions that were present at the time of service, but not disclosed at the time of the skin care procedure, which may be affected by the treatment today.

Parent/Guardian Name