NeoGen Consent Form Please enable JavaScript in your browser to complete this form.First Name *Last Name *Date of Birth *Cell Phone Number *Email *MEDICAL CONDITIONS: Check any of the boxes that apply to you *Are you considered to be ineligible for general surgeryDo you have any CIEDs (pacemakers)Any implantable electronic devicesTendency to keloid or impaired wound healing processActive skin infections - (psoriasis, sores, eczema, or any type of rashHistory of viral herpes - (need to medicate 3 days prior 3 days post)Used oral tretinoins such as Accutane, within 6 months prior to treatmentBroken skin, or any inflammatory skin condition, in the vicinity of the treatment areaPregnant or nursingUse of self-tanning products within 1 week of treatmentFitzpatrick skin types V and VIExperience VitiligoTopical steroids to the treatment area (discontinue 7 days prior)None of the above applyNeoGen Consent *I agree to the NeoGen Consent FormI understand that the NeoGenTM is intended for the treatment of wrinkles and rhytides, superficial skin lesions, actinic keratosis, viral papillomata, seborrhoeic keratosis, and acne scars and that the clinical results may vary. I understand that there is a possibility of side effects such as infection, scarring, and permanent discoloration as well as short-term effects such as reddening, mild burning sensation, temporary bruising, and temporary discoloration of the skin. These effects have all been fully explained to me. The NeoGenTM PSR System is intended for the treatment of the following dermatological conditions: • Treatment of wrinkles and rhytids • Superficial skin lesions • Actinic Keratosis • Viral Papillomata • Seborrheic Keratosis • Acne Scars & Acne Notes: 1. Actinic Keratosis can lead to more serious squamous cell carcinoma (SCC) if left untreated. Up to 40% of SCCs begin as actinic keratoses. Failure to treat these pre-malignant lesions effectively at an early stage substantially increases the risk of more acute surgery with its associated morbidity and patient discomfort. 2. Acne Scars are treated as a poor prognostic indicator due to their appearance and permanency and therefore they are an indication for medical treatment to minimize the psychological effects such as social withdrawal, depression, and anxiety. I give permission for photographs and other audio-visual and graphic materials to be used by the physician’s practice or by Energist Ltd for marketing, and education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos. I have read and I understand this agreement and all my questions have been addressed and answered to my satisfaction. I agree to the terms of this agreement.Date of Signature *Send
