Geneo client consent form Client Name *Date of birth *PhoneGenderMaleFemaleStreet AddressCityZIP / Postal CodeExisting or recent illness *Hospitalisations/SurgeryMedicationsMedication intoleranceAny Aesthetic ProceduresGDPR *Yes, I agree with the privacy policy and terms and conditions.Over 18 years of ageYesNoPacemaker or internal defibrillator or other implanted neurostimulators or any other internal electric deviceYesNoMetal implants in the treatment areaYesNoPregnancy or nursingYesNoCurrent or history of cancer, especially skin cancer, or pre-malignant molesYesNoImpaired immune system due to Immunosuppressive diseases such as AIDS and HIV, or use of immunosuppressive medicationsYesNoSevere concurrent conditions such as cardiac disorders, epilepsy or lupus.YesNoPoorly controlled endocrine disorders, such as diabetesYesNoHistory of bleeding coagulopathies, or use of anticoagulantsYesNoA history of diseases stimulated by heat, such as recurrent Herpes Simplex in the treatment areaYesNoDiminished or exaggerated perception of temperature changesYesNoAny 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 skinYesNoHistory of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skinYesNoHistory of skin disorders such as keloid scarring, abnormal wound healing, as well as very dry and fragile skin.YesNoAny surgical, invasive, ablative procedure in the treatment area before complete healingYesNoAny medical condition that might impair skin healingYesNoAre 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 WortIf yes then please specifyHave you had Aesthetic procedures in the treatment area, such as FillersIf yes please specifyDate treatedIf yes please specifyGold/Plastic ThreadsYesNoFat implantsYesNoIf other please specifyI the undersigned, pledge to inform of all changes in my physical conditionYour browser does not support e-Signature field.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)Your browser does not support e-Signature field.I accept that any treatment I have taken is at my own risk. I certify that i have read and completed the above to the best of my knowledge. I understand that failure to disclose information requested above may result in adverse side effect, unknown because of this to which I accept full liability/responsibility I fully understand the above concent/permit and treatment/s to be carried out. The undertaken of the treatment/s has been fully explained to me. I accept full responsibility for this and or other complications which may arise or result during or following any procedure that is performed at my request.Your browser does not support e-Signature field.Submit
