• Geneo+ Consultation Form

    Client Details
  •  /  /
    Pick a Date

  • Health Questionnaire

  • Have you tested positive to Coronavirus?
                
    If yes selected, we will be unable to perform a treatment for you at this time.

  • Conditions

  • Do you have or have you experienced any of the following conditions?
    (Please indicate if any)

    • Under 18 years of age:           
    • Pacemaker or internal defibrillator or other implanted neurostimulators or any other internal electric device:           
    • Metal implants in the treatment area:          
    • Pregnancy or nursing:           
    • Current or history of cancer, especially skin cancer, or pre-malignant moles:         
    • Impaired immune system due to immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medications.:           
    • Severe concurrent conditions such as cardiac disorders, epilepsy or lupus:           
    • Poorly controlled endocrine disorders, such as diabetes:           
    • History of bleeding coagulopathies, or use of anticoagulants:           
    • A history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment area:           
    • Diminished or exaggerated perception of temperature changes:           
    • 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:           
    • Any medical condition that might impair skin healing:           

  • Are you taking any of the following medications and supplements?
    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.         
    If yes, please specify:      

  • Have you had Aesthetic procedures in the treatment area, such as:
    Fillers:        
    If yes, please type name of filler:      .
    Date treated:   Pick a Date   
    Gold / plastic threads:       
    Fat implants:       
    Other, please specify:      

  • I, the undersigned, pledge to inform of all changes in my physical condition.
     
    I agree to undergo the treatment, as detailed below in this document. I was explained to and I understood the results, the chances and the course of the treatment.
    I confirm that I do not suffer from 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    (therapist) .

  • The TriPollar technology:

  • TriPollar is a radiofrequency (RF) technology indicated for the treatment of facial wrinkles and rhytides. The RF energy heats the skin’s dermal layer to stimulate a process of new collagen production and tightening of the existing collagen.

    • The TriPollar treatment induces focused heating of the dermal layer which stimulates a process leading to collagen generation and replenishment.
    • The treatment creates a warm sensation over the skin surface.
    • I understand that consenting to the treatment course is my choice and that I am free to withdraw at any time, without providing any reason.
    • I was informed about the possible side effects of the treatment including: local pain, skin redness (erythema), swelling (edema), damage to the natural skin texture (crust, blister and burn), change of skin pigmentation, fragile skin and bruising. Although these effects are rare and are expected to be temporary, any adverse reaction should be reported immediately.
    • I am aware of the possibility of receiving other type of treatments using the GeneO device, after signing a relevant consent.
    • I hereby approve use of the photos and results for scientific publications and marketing material (such as brochures, website, and presentations). These publications should be done while maintaining my privacy and identification.

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

  • Client Name: Date   Pick a Date  

  • Clear

  • Therapist Name: Date   Pick a Date  

  • Clear
  • Should be Empty: