Oxygeno HEALTH DECLARATION + CONSENT FORM

CLIENT CONTACT INFORMATION

MEDICAL HISTORY:

Hospitalizations/Surgery

Existing or recent illnesses

Medications

Medication intolerances

Any known allergies (including allergies to cosmetic products”)

Previous aesthetic procedures in the treatment area (including dates of treatments)

” Please check the list of ingredients in the OxyGeneo TM products that are intended for use (OxyPod TM, Primer gel, and matching serum)

Do you have or have you experienced any of the following conditions?

if YES, please specify

Current or history of cancer, especially skin

Current or history of cancer, especially skin

 Yes

 Yes

No

No

Pacemaker or internal defibrillator, implanted neuro-stimulators, or any other internal electric device

 Yes

No

Metal implants or other implants in the treatment area (not including dental implants and fillings)

 Yes

No

Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications.

 Yes

No

Conditions which could be adversely affected by heat (such as recurrent Herpes Simplex)

 Yes

No

Sensory impairment in the treatment area

 Yes

No

Diminished or exaggerated perception of temperature changes

 Yes

No

Are you currently pregnant or nursing?

 Yes

No

Any active skin condition in the treatment area? (e.g. sores, eczema, rash, fragile skin, swollen skin, burnt or injured skin, active acne, rosacea, dermatitis, psoriasis, active Herpes Simplex)

 Yes

No

Freshly tanned skin (within the last few days)

 Yes

No

Vascular disorders in the treatment area (e.g. thrombosis, varicose, phlebitis)

 Yes

No

Severe concurrent disease such as: uncontrolled diabetes, epilepsy, cardiac disorders, lupus, and cancer

 Yes

No

Botox or Fillers within the last two weeks

 Yes

No

Accutane (Isotretinoin) / Retin-A within the last 6 months

 Yes

No

Chemical peels, Laser skin resurfacing, or Fractional RF resurfacing within the last 3 months?

 Yes

No

History of severe allergic reactions (e.g. hives) to cosmetic ingredients

 Yes

No

History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.

 Yes

No

I, the undersigned, pledge to inform the clinic of all changes in my health condition.

TREATMENT OVERVIEW

OxyGeneo’M treatment:

  • OxyGeneo TM is a 3-in-1 non-invasive treatment that includes superficial skin exfoliation, tissue oxygenation, and skin nourishment with active cosmetic
  • Before the treatment begins, a special treatment gel (Primer Gel) is applied to the
  • During treatment, the practitioner uses a vibrating exfoliation capsule (OxyPod TM) that reacts with the Primer gel on the skin to exfoliate, oxygenate, and nourish the skin with therapeutic
  • The reaction between the OxyPod TM and the Primer Gel generates an abundance of carbon dioxide (CO2)bubbles on the skin's The body then responds by sending more Oxygen to the skin to replace the CO2. in a natural physiological process called the Bohr Effect. This process results in optimal tissue oxygenation.
  • The exfoliation lasts 5-15 minutes, depending on the treated area. A mild tingling sensation is expected in the first few minutes, accompanied with mild erythema (redness). These reactions are temporary and resolve spontaneously within a few
  • After the exfoliation is done, a soothing serum is applied to alleviate redness and restore skin moisture. The serum has more active ingredients that complete the activity of the OxyPod TM. The serum is applied manually or with a dedicated Ultrasound
  • Possible side effects of the OxyGeneo TM treatment include: redness, swelling, itching, irritation, scratches, transient breakouts, capillary damage, skin sensitivity, allergic reactions, and change of Please note — these side effects are rare, and usually resolve within 24 hours. In case of excessive side effects lingering more than 24 hours, the client should contact their treating physician for follow-up care.

OxyGeneo’M post-treatment care:

The OxyGeneo TM treatment has no downtime and generally no special post-treatment care is needed. However, it is recommended to use hydrating mask/moisturizer after treatment, followed by sun protection cream with SPF 30 or more. More post-treatment instructions may be provided by the treating clinician.

Ultrasound treatment:

  • The Ultrasound applicator is used for the second part of the OxyGeneoTM treatment in conjunction with the OxyGeneo TM serum, to increase the absorption of serum ingredients into the
  • The Ultrasound treatment is based on low-intensity ultrasound energy that temporarily increases the gaps between skin cells to allow more ingredients to reach the deeper layers of the This process is commonly known as Sonophoresis and is widely used in hospitals for trans-epidermal drug delivery.
  • The Ultrasound treatment is painless and does not require numbing of the As the Ultrasound probe glides on the skin, a slight heat sensation is expected with minimal erythema. There is no downtime or special post-treatment care regimen.
  • In addition to increased absorption of active ingredient, the Ultrasound treatment helps to increase local blood and lymph flow, shrink enlarged pores, and reduce puffiness under the
  • Side effects to the Ultrasound treatment are extremely They include excessive pain and redness (erythema), blisters, breakouts, superficial burns, excessive swelling (edema), and bruising. In case of excessive side effects lingering more than 24 hours, the client should contact their treating physician for follow-up care.

TriPollar® treatment:

  • TriPoIIar^ is a non-invasive skin tightening and wrinkle-reduction treatment that is based on radiofrequency (RF)
  • The TriPollara applicator utilizes four RF electrodes that work simultaneously to deliver focused energy to the deeper layers of the The RF energy generates heat within these layers and stimulates the synthesis of new, healthy, and stronger skin fibers such as collagen and elastin.
  • The TriPollar° treatment begins by applying a thin layer of glycerin gel on the As the RF probes glide on the skin's surface, heat is gradually and safely built up within the skin, until a maximum temperature of 41°C is achieved on the skin's surface.
  • The TriPollaratreatment feels like a warm massage and lasts for 20-30 Heat sensation and redness are common reactions.
  • Immediately after the TriPollar®treatment, the skin is expected to appear tighter and smoother with less visible However, the immediate post-treatment effect is temporary. To achieve a longer lasting skin tightening effect, multiple treatments are usually required.
  • Possible side effects of the TriPollar° treatment may include: redness (erythema), swelling (edema), transient breakouts, bruises, superficial burns, irritation, skin sensitivity, and Please note — these side effects are rare, and usually resolve within 24 hours. In case of excessive side effects lingering more than 24 hours, the client should contact their treating physician for follow-up care.

CLIENT CONSENT

I, the undersigned, agree to undergo OxyGeneo TM treatment, along with Ultrasound infusion and TriPoIIar^ skin tightening, as detailed in this document. The treatment was explained to me and I understand the course of treatment, expected results, possible side effects, and post-treatment regimen.

I confirm that I am not contraindicated to any of the above-described conditions.

I have had the opportunity to consider the following information, ask questions and have had these answered satisfactorily by      (clinician/ therapist/practitioner).

I understand that receiving the OxyGeneo TM treatment is my choice.

I am aware of the possible side effects of the treatment and pledge to inform the clinic/spa of any

.excessive reaction that lasts for more than 24 hours after the treatment

I hereby approve use of my photos and results for scientific publications and marketing materials (such as brochures, websites, and training presentations). I understand that in such publications I shall not be recognizable, and my identity and private information will remain protected and not published.

I confirm that I have read and understand the above information and consented to the treatment out of my own free will.