Consent – Le' Spa by Ryana

CONSENT FORM

Client's Name:

Date Of Birth:

Clinician's Name:

Date of Service:

OxyGeneo

Ultrasound

All Handpieces

Pregnant or nursing?

Yes No

Under the age of 18 years old?

Yes No

Metal implants in treatment area (not Including dental implants of fillings)?

Yes No

Pacemaker, internal defibrillator, implanted Neurostimulators or any other infernal eclectic system?

Yes No

History of skin disorders, keloid scaring, abnormal wound healing, or very dry skin?

Yes No

Impaired immune system due to Immunosuppressive disease such as AIDS or HIV, or use of immunosuppressive medication?

Yes No

Fresh tan within the last 3 days?

Yes No

Coagulopathies, vascular or bleeding disorders, telangiectasia, varicose veins, thrombosis, phlebitis in the treatment area?

Yes No

Current history of skin cancer, neoplastic tissue, pre- malignant moles, cyst, abscesses or other?

Yes No

Known allergies to cosmetics, products, or experience allergic reactions live hives?

Yes No

Using Accutane or retinol products?

Yes No

Last use of the above products:

Any aesthetics, ablative, surgical, invasive procedure (plastic/cosmetic surgery), skin resurfacing, chemical peel, dermabrasion, any fillers or botox?

Yes No

Last date of the above cosmetic procedures:

Severe concurrent disease such as un-controlled diabetes, nervous diseases, or cardiac disorder?

Yes No

Active eczema rash, fragile skin, swollen, rosacea, dermatitis, psoriasis, herpes simplex, or burnt skin?

Yes No

List all skin care products or over the counter medications:

Client's Name:

Date Of Birth:

Clinician's Name:

Date of Services:

Please review the following:

I understand there may be some degree of minor discomfort, i.e. scratches or itchiness.
I understand that to achieve maximum results, | 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 | 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 will have this treatment performed on me and wil follow all prescribed directions above.
I have read the pre and post Instruction sheet and | agree to all the above.

I agree to have my before and affer photo(s) released to my provider and Geneo?

Yes No

My questions have been answered by the staff to my complete satisfaction. I accept the risks and complications of the procedure.

Print Name:

Date of Birth

Signature

Witness Intials:

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CONSENT FORM

Le' Spa by Ryana

By appointments only

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