It is important you clearly mark any areas of this form you wish to have clarified or discussed further. It is ultimately YOUR responsibility to ensure you understand, in full, the PRX Treatment* application and the expected outcomes BEFORE your treatment commences. PLEASE READ ALL OF THE FOLLOWING CAREFULLY AND SIGN, WHERE INDICATED. You must ensure all points below have been exhaustively explained by your specialist. You are signing to state you understand and accept the terms of your treatment. 

*PRX Derm Perfexion,PRX-PLUS or PRX C

TERMS OF YOUR TREATMENT:

PRX  is an elective cosmetic procedure that are not medically necessary. For optimal results to be achieved you may be required to return for additional treatments before your overall procedure is deemed complete.

I MUST INFORM THE TECHNICIAN IF:

• I am pregnant or breastfeeding.
• I am using Isotretinoin or topical retinoids.

IN THE DAYS FOLLOWING THE APPLICATION. THE FOLLOWING REACTIONS MAY ARISE:

• Widespread or patchy redness, which in extremely rare cases can last up to a few days.
• Late exfoliation, that can last a few days if the stratum corneum is highly thick.
• Darker round spots over the next two days: these are due to the drying of thicker skin areas. They will disappear with natural exfoliation in a few days.

SIDE EFFECTS:

• Conjunctival irritation due to unintentional contact.
• Itchiness alongside reddening, papules and ‘micro’ blisters, due to allergic reaction to kojic acid, glycolic acid or latex gloves (if used).
• Redness, itching or delayed inflammation after the treatment, next day or days after, it is possibly due to: Extremely dry skin or geographical location (e.g. in very cold weather), irritation of skin that was not completely undamaged at the time of application (subclinical dermatitis, recently waxed/shaved skin, etc.), or an allergy to active ingredients (very rare).
• Skin abrasions caused by a too vigorous massage. If this is the case, scarring and hyperpigmentation may appear.
• In the event of side effects causing persistent inflammation, there is a risk of hyperpigmentation in predisposed subjects.

CONTRAINDICATIONS:

• Irritated skin
• Compromised skin 
• Seborrheic dermatitis
• Allergy to listed ingredients
• Pregnancy and breastfeeding
• Cutaneous and/or herpetic eruptions
• Keloid scars
• Cutaneous lupus

MICRONEEDLING

SIDE EFFECTS

After the procedure, the skin will be red and flushed in appearance, similar to a moderate sunburn. You may also experience skin tightness and mild sensitivity to touch on certain areas. This will diminish significantly within a few hours following the procedure. Within the next 24 hours, the skin will have returned to normal. After three days, there is rarely any evidence that the procedure has taken place.

CONTRAINDICATIONS
Microneedling is contraindicated for patients with: keloid scars, scleroderma, collagen vascular diseases or cardiac abnormalities, a hemorrhagic disorder or haemostatic dysfunction, active bacterial or fungal infection.

PRECAUTIONS AND WARNINGS
Microneedling has not been evaluated in the following patient populations, and as such, precautions should be taken when determining whether the procedure is adequate for the patient: scars and stretch marks less than one year old; women who are pregnant or nursing; keloid scars; patients with history of eczema, psoriasis and other chronic conditions; patients with history of actinic (solar) keratosis; patients with history of herpes simplex infections; diabetics or patients with wound-healing deficiencies; patients on immunosuppressive therapy; and skin with presence of raised moles or warts on targeted area.

I certify that the preceding medical and personal statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical health and to update them in the event of any changes.

I hereby authorize WiQo® US, Inc., to perform the PRX Professional Treatment* application on me (with or without Microneedling). I understand that multiple treatments may be needed and in rare cases no improvement may be seen.

My questions regarding this procedure have all been answered to my satisfaction I understand the procedure and accept the risks. I hereby release the technician and all affiliated with WiQo® US, Inc. from all liabilities associated with the above indicated procedure throughout the treatment process.

No guarantee, warranty, or assurance has been made to me as the results that may be obtained. I am aware that additional treatments may be necessary for desired results. Clinical results vary patient to patient, and I understand that. I agree to adhere to all safety precautions, pre and post care during treatments.

ACKNOWLEDGEMENT: BY MY SIGNATURE BELOW, I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE CONTENTS OF THE PERMISSION FORM FOR PRX PROFESSIONAL TREATMENT* (WITH OR WITHOUT MICRONEEDLING) AND THAT THE DISCLOSED HEREIN WERE MADE TO ME.

*PRX DERM PERFEXION OR PRX-PLUS

I hereby irrevocably grant, pursuant to Article 96 of the Italian Copyright Law, to WIQO S.p.A, registered office in (20142) Milan (MI), Via Frà Cristoforo 14/D (“WIQO”) the exclusive and unconditional rights of use, without any territorial and/or temporal limitation, including the rights to publish, reproduce, communicate, disseminate, transmit, synchronize, market, assign, modify, in any form or manner (including but not limited to frames, footage, clips, videos, photographs, computer-generated images, drawings, etc.), in whole or in part and in any medium, portrait, image, name, voice, my personal data (the “Images”) collected, recorded and/or made for social platforms or video channels, including video footage, photographs, recordings, for any purpose whatsoever, without any limitation and/or restriction, and for any commercial, promotional and marketing use, including but not limited to the following uses: scientific research, presentations at scientific conferences, advertising campaigns, and any further promotional use associated with the PRX product and/or any other product of WIQO's WIQo and WiQoMed Line and/or promotional and/or product presentation to the public at sale points or spaces (direct and/or of third parties), for use within all premises owned and/or available to WIQO, including websites (e.g. the Be.WIQO) and anywhere on the world wide web, brochures, print-outs, displays, folders, newspapers, magazines, billboards, catalogs, labels, and hashtags; dissemination to press agencies, media outlets in general, professionals in the field of aesthetic medicine, and any other entity providing information to the public (whether specialized or not), by any means whatsoever, including events, invitations, sponsorships, and inclusion in editorials and articles written by third parties regarding the activities of WIQO or its products, inclusion in archives for the preparation, study, and development of products; for the organization of scientific and/or medical conferences; for the production of promotional videos about the company or its products; and for all internal promotional events. It is understood that WIQO undertakes to anonymize, as far as possible, the Images used for promotional and marketing purposes, although it cannot guarantee the complete removal of any identifying marks. In any case, WIQO shall not be held liable for any use of the Images that differs from what was originally agreed on, by any press agency, newspaper, magazine, television network, or media outlet in general, regardless of the medium used (print, internet, etc.). It irrevocably undertakes not to object to any modification and/or alteration of the Images as long as the same do not cause objective harm to the honor and reputation of the undersigned.

PRIVACY POLICY

Purpose: Pursuant to Art. 13 of EU Regulation 679/2016, WIQO informs that the personal data acquired as indicated above are processed in accordance with Legislative Decree 196/2003, as amended, and EU Regulation 679/2016 (“GDPR”), with or without electronic means, for the purposes outlined above, as well as for administrative, accounting, and tax purposes.

Obligatory or Optional Provision: The provision of Your data is optional. Failure to provide consent will prevent the use of images and/or audiovisual recordings of the data subject for the purposes indicated above.

Communication and Dissemination: Within the limits relevant to the processing purposes indicated, personal data (images and audiovisual recordings) may be disclosed to press agencies, media outlets in general, professionals in the medical-scientific sector, and any other entity providing information to the public (both specialized and general). The data may also be disseminated through advertising articles in various media outlets.

Data Controller: WIQO S.p.A., headquartered in (20142) Milan (MI), Via Fra' Cristoforo 14/D, and operational headquarters in (34015) Muggia (TS), Via Martinelli 16, P.IVA/C.F. 11269510159, Email contact@wiqo.com

Data Processors: WIQO may need to transfer Your personal data to external service providers for further data processing ("data processors"). WIQO requires the above-mentioned data processors to use Your personal information only in accordance with our guidelines and in accordance with this privacy policy, as well as in accordance with the requirements of and in compliance with EU Regulation 679/2016 and Legislative Decree 196/2003 as amended. The list of Data Processors is available at the operational headquarters of the Data Controller in (34015) Muggia (TS), Via Martinelli 16.

Rights of the data subject: At any time, you may exercise your rights with respect to the Data Controller, pursuant to Articles 15 to 22 and Article 34 of the GDPR. To exercise these rights, you must contact the Data Controller by sending an email to the following address: contact@wiqo.com.

Retention Period: The collected data will be retained for no longer than is necessary to achieve the purposes for which they are processed (“storage limitation principle”), in accordance with Article 5 of the GDPR, and/or for the period required to fulfill legal obligations. The relevance and necessity of the retained data in relation to the purposes for which they were collected are periodically reviewed.

I HAVE READ AND UNDERSTAND THE ABOVE PHOTO RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE, OR, IF I AM UNDER 18 YEARS OF AGE, I HAVE OBTAINED THE REQUIRED CONSENT OF MY PARENTS/GUARDIANS AS EVIDENCED BY THEIR SIGNATURES BELOW. I ACCEPT