Glo2Facial Consent Form

Name*

First NameLast Name

Date of Birth*

Date

DESCRIPTION OF THE PROCEDURE:

Glo2Facial is a 3-step treatment combining Oxfoliation (exfoliation + oxygenation of the skin), Ultrasound Infusion, and Massage via the device. An Oxypod will be chosen based on your skin type to exfoliate and create a Co2-rich environment on the skin’s surface. As a result, the body naturally sends a rush of oxygen, improving the overall nourishment and brilliance of the skin. Manual extractions may be preformed after exfoliation if necessary and desired. Ultrasound technology then creates micro-vibrations that smooth the surface of the skin and allow the nutrients to penetrate the skin’s protective barrier, improving their overall effectiveness. The treatment is finished with hands-free massage to reduce puffiness and redness, leaving the skin calmed and glowing.

WHAT TO EXPECT:

During the procedure, the skin will feel hot during the Oxygenation step as the Bohr Effect is signaling the body to send oxygen-rich blood to the area. This sensation will subside within a few minutes. There is no downtime with the Glo2Facial, though it's advised to avoid sweating the rest of the day after treatment to allow the products to penetrate the skin as best as possible. Following treatment, the skin barrier is strengthened allowing for improved skin health, a temporary tightening effect of the skin may be noticed, and the skin will feel smoother and appear brighter.

Are you pregnant or breastfeeding? (Treatment can be modified to be pregnancy or breastfeeding-safe.)*

Yes, pregnantYes, breastfeedingNo

Are you currently or have you within the last 3 months been on Accutane (Isotretinoin)?*

YesNo

Do you have any metal implants in the face (or treatment area) excluding dental work? (Treatment may be modified to be made safe.)*

YesNo

Do you have any heart conditions or any electronic devices inside the body (i.e. pacemaker)? (Treatment may be modified to be made safe.)*

YesNo

Please explain:

Have you had any injectables (Botox, Dysport, Filler, etc.) within the 2 weeks prior in the area of treatment?*

YesNo

Please explain which/where:

I will discontinue exfoliants such as physical scrubs, AHAs/BHAs (i.e. Glycolic Acid, Lactic Acid, Salicylic Acid, etc.), and retinoids (i.e. Retinol, prescription Retinoic Acid, etc.) within 3 days prior to treatment.*

YesI am unsure if my products contain these ingredients

Although it is impossible to list every potential risk and complication, the following conditions are recognized as contraindications for the Glo2Facial treatment and must be disclosed prior to treatment:

Active acne (Grades 3 & 4)
Active infection of any type, such as herpes simplex, flat warts, or conjunctivitis
Any recent chemical peel or laser procedure within 2 weeks prior to treatment on area of treatment
Botox, Dysport, or Filler injections within 2 weeks prior to treatment on area of treatment
Chemotherapy or radiation
Eczema or dermatitis present on area of treatment
Skin cancer on area of treatment
Sunburn
Recent/unhealed tattoos or piercings in and around areas of treatment (including microblading, permanent makeup, etc.)

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Date*

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