Healthcare Oxygeneo Consent Form

Healthcare OxyGeneo Consent Form

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information (if applicable)

Medical History

Please indicate any of the following that apply by checking the box:

Pregnant, breastfeeding, or trying to become pregnant
Cardiac pacemaker or implanted electrical device
Isotretinoin (Accutane) use within past 6 months
Active cold sores, skin infection, or open wound in treatment area
Autoimmune disorder or immunosuppressive therapy

Procedure: OxyGeneo Treatment

The OxyGeneo procedure combines exfoliation, oxygenation and topical infusion. The intended benefits include improved skin texture, hydration, and radiance. I understand that results vary and no guarantee is made as to the degree of improvement.

Risks, Complications, and Alternative Treatments

I acknowledge that I have been advised of the potential risks and complications associated with OxyGeneo treatments, which may include but are not limited to: transient redness, swelling, bruising, tenderness, pigmentary changes (hyperpigmentation or hypopigmentation), allergic reaction to topical agents, scarring, infection, and unsatisfactory cosmetic outcome. Rare complications may require additional medical treatment.

Alternative skin care options, including topical therapies, peels, laser procedures, or no treatment, have been explained to me and I have had the opportunity to ask questions.

Acknowledgments and Consents

By initialing and signing below, I acknowledge and consent to the following statements:

I have read and understood the explanation of the procedure and the risks, and all of my questions have been answered to my satisfaction. Initials:

I authorize the administration of topical preparations and the use of OxyGeneo equipment as recommended by the treating clinician. Initials:

I consent to the application of topical anesthetic agents if needed and understand their risks. Initials:

I consent to the taking of clinical photographs for medical records and treatment planning. I also consent to the use of de-identified photographs for educational purposes. I understand separate authorization will be required for promotional use beyond de-identified educational purposes.
Consent to photography for medical records and de-identified education: Yes No

HIPAA / Privacy and Authorization to Release Information

I acknowledge receipt of the practice's Notice of Privacy Practices. I authorize the release of my protected health information to my insurer and to third parties as necessary for treatment, payment, and healthcare operations. I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance upon it.

Aftercare and Post-Treatment

I understand post-treatment instructions will be provided. I agree to follow aftercare instructions including sun protection and avoidance of irritants. I will notify the clinic promptly if unexpected symptoms arise.

Release, Indemnification and Acknowledgment

I release and hold harmless the treating clinician, supervising physician, and clinic from liability for complications arising from the procedure except in cases of gross negligence or willful misconduct. I agree to indemnify the provider for claims arising from my failure to follow instructions or from inaccurate medical history provided by me.

I acknowledge that no guarantees have been made to me regarding the results of the treatment and that supplemental or alternate treatments may be recommended.

Patient Certification

I certify that the information I have provided on this form is accurate and complete to the best of my knowledge. I have had the opportunity to ask questions about the procedure, risks, benefits and alternatives, and my questions have been answered to my satisfaction. By signing below I consent to undergo OxyGeneo treatment.

Sign Now