Reemake Skin Medical Spa + Laser Clinic

Reemake Skin

Oxygeneo Consent Form

First Name:

Last Name:

Date Of Birth:

Tel:

Mobile:

Email:

Gender:
MaleFemaleOther
Address
Address 1:

City:

Postal Code:

Health Questionnaire:

Existing or recent illnesses:
Hospitalizations/Surgery:
Medications:
Medication intolerance Allergies (including to cosmetic products)* :

Aesthetic Procedures in treatment area:

*Check also list of OxyGeneO ingredients on the package

Do you have or have you experienced any of the following conditions?
Under 18 years of age YesNo
[group group-1] If YES, please specify: [/group]

Current or history of cancer, especially skin cancer or pre-malignant moles YesNo
[group group-2] If YES, please specify: [/group]

Pacemaker or internal defibrillator, implanted neuro-stimulators, or any other internal electric device YesNo
[group group-3] If YES, please specify: [/group]

Metal implants or other implants in the treatment area (not including dental implants and fillings) YesNo
[group group-4] If YES, please specify: [/group]

Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications. YesNo
[group group-5] If YES, please specify: [/group]

Conditions which could be adversely affected by heat (such as recurrent Herpes Simplex) YesNo
[group group-6] If YES, please specify: [/group]

Sensory impairment in the treatment area YesNo
[group group-7] If YES, please specify: [/group]

Diminished or exaggerated perception of temperature changes YesNo
[group group-8] If YES, please specify: [/group]

Are you currently pregnant or nursing? YesNo
[group group-9] If YES, please specify: [/group]

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) YesNo
[group group-10] If YES, please specify: [/group]

Freshlytanned skin (within the last few days) YesNo
[group group-11] If YES, please specify: [/group]

Vascular disorders in the treatment area (e.g. thrombosis, varicose, phlebitis) YesNo
[group group-12] If YES, please specify: [/group]

Severe concurrent disease such as: uncontrolled diabetes, epilepsy, cardiac disorders, lupus, and cancer YesNo
[group group-13] If YES, please specify: [/group]

Botox or Fillers within the last two weeks YesNo
[group group-14] If YES, please specify: [/group]

Accutane (Isotretinoin) / Retin-A within the last 6 months YesNo
[group group-15] If YES, please specify: [/group]

Chemical peels, Laser skin resurfacing, or Fractional RF resurfacing within the last 3 months? YesNo
[group group-16] If YES, please specify: [/group]

History of severe allergic reactions (e.g. hives) to cosmetic ingredients YesNo
[group group-17] If YES, please specify: [/group]

History of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin. YesNo
[group group-18] If YES, please specify: [/group]

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

TREATMENT OVERVIEW

OxyGeneo™ treatment:

• OxyGeneo™ is a3-in-1 non-invasive treatment that includes superficial skin exfoliation, tissue oxygenation, and skin nourishment with active cosmetic ingredients.

• Before the treatment begins, a special treatment gel (Primer Gel) is applied to the skin.

• During treatment, the practitioner uses a vibrating exfoliation capsule (OxyPod™) that reacts with the Primer gel on the skin to exfoliate, oxygenate, and nourish the skin with therapeutic ingredients.

• The reaction between the OxyPod™ and the Primer Gel generates an abundance of carbon dioxide (CO2) bubbles on the skin’s surface. 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 minutes.

• 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™. The serum is applied manually or with a dedicated Ultrasound applicator.

• Possible side effects of the OxyGeneo™ treatment include: redness, swelling, itching, irritation, scratches, transient breakouts, capillary damage, skin sensitivity, allergic reactions, and change of pigmentation. 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™ post-treatment care:
The OxyGeneo™ 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.

TriPollar® treatment:

• TriPollar® is a non-invasive skin tightening and wrinkle-reduction treatment that is based on radiofrequency (RF) energy.

• The TriPollar® applicator utilizes four RF electrodes that work simultaneously to deliver focused energy to the deeper layers of the skin. 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 skin. 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 41oC is achieved on the skin’s surface.

• The TriPollar® treatment feels like a warm massage and lasts for 20-30 minutes. Heat sensation and redness are common reactions.

• Immediately after the TriPollar® treatment, the skin is expected to appear tighter and smoother with less visible wrinkles. 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 blisters.

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™ treatment, along with TriPollar® 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 Reemake Studio.

I understand that receiving the OxyGeneo™ 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.

Date:
Patient Name:
Patient Signature:

Date:
Practitioner Name:
Practitioner Signature: