Patient Consent Form for Tixel Treatment

Step 1 of 4

in area(s) Treatment

This form is designed to provide you with the information you need to make an informed decision on whether or not to have a Tixel treatment performed. If you have any questions or do not understand any part of this consent, please do not hesitate to ask us.

I hereby authorize these clinicians to perform Tixel treatment on me. I understand that the procedure is purely elective and I have chosen to receive treatment for:

Treatment of

in this/these area(s)

Treatment of

in this/these area(s)

I understand the nature of my condition, the nature of the procedure, the alternative treatments available, and the benefits to be expected compared with alternative approaches. I understand that optimal results are achieved only with a series of treatments and that I will not see optimal results after one treatment. The need to complete a treatment plan has been fully explained to me.

Just as there are benefits to the procedure proposed, I understand that this procedure also involves risks. I understand that serious complications are very rare, but are possible. Common side effects include temporary slight swelling and “pinkness” (similar to a mild sunburn). The temporary side effects generally last a few hours, but may last 1-2 days. Bronze microspots usually appear after 1-2 days and will last 1-2 days until they flake off. For treatments with very aggressive settings, some patients might experience mild exudate and flaking/peeling of skin in the aggressively-treated area. Other potential risks include milia/acne or Herpes Simplex breakout, itching, pain, or minor infection. There is a rare possibility of burn, blistering, erosion or a scar at the treatment site may develop.

I consent to photographs/videos being taken to evaluate treatment effectiveness and for medical education and training.

“Before and After Instructions” have been discussed with me. The procedure, as well as potential benefits and risks, have all been explained to my satisfaction. I have had all my questions answered. I freely consent to the proposed treatment. I certify that I am a competent adult of at least 18 years of age, or that if I am a minor under the age of 18, I understand that the consent of my parent/legal guardian/person having legal custody will also be required before treatment.

Patient Signature

Clear Signature

Print Patient Name *

Date

Save and Resume Later

Day 1

Day 2

Day 3

Days 4-7

Avoid all sun and UV exposure. If outdoors during daylight for short periods, use shade protection such as sun hats or visors.

For 24 hours after treatment, only apply recommended products to skin. Pat on, do not rub. (See provider’s instructions below the chart).

After the initial 24 hours, apply (pat on) water-based hydration (such as low-molecular weight hyaluronic aced) as often as needed.

Sleep on back with head slightly elevated to decrease swelling.

Continue to avoid all sun and UV exposure. If outdoors during daylight for short periods, use shade protection such as sun hats or visors.

Gently cleanse skin twice daily with simple cleanser, then apply water-soluble emollient (pat on skin, do not rub). Reapply water-based emollient as often as needed.

You can use a gentle mineral make-up on day 2, if cleared by your provider (only for low to moderate settings).

Swelling may be increased today, continue to sleep with head elevated.

Continue to avoid sun and UV exposure. Use SPF 50 UV protection and/or wide-brimmed hats when outdoors.

Continue gentle cleansing morning and night followed by applying a generous amount of emollient. Continue to apply emollient as needed.

Redness and swelling should be starting to decrease and is usually gone after 5 days.

Treatment dots, or micropores, begin to slough off on days 3-7.

White vinegar soaks may help with exfoliation (1tbs:1cup).

•Always apply SPF50 physical sunblock (zinc oxide, titanium oxide, etc.) before going outdoors, consider sun hats or visors.

Continue gentle cleansing

twice daily.

•Use recommended treatment serum or moisturizer.

Mineral make-up may be used, if skin is healing normally (no drainage, open areas, or raised scabs).

•When treatment dots are no longer or barely visible, and if skin has healed normally, resume your normal skin regimen or begin recommended routine skin regimen, as directed by your provider.

Save and Resume Later

Legal Disclosure
ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
Please read the following information carefully. By clicking the 'I agree' button, you agree that you have reviewed the following terms and conditions and consent to transact business electronically using Zoho Sign electronic signature system. If you do not agree to these terms, do not click the 'I agree' button.

Electronic documents
Please note that Novoxel Inc. ("we", "us" or "Company") will send all documents electronically to you to the email address that you have given us during the course of the business relationship unless you tell us otherwise in accordance with the procedure explained herein. Once you sign a document electronically, we will send a PDF version of the document to you.

Request for paper copies
You have the right to request paper copies of these documents sent to you electronically from sign@tixel.us. Alternatively, you also have the ability to download and print these documents sent to you electronically, and re-upload a scanned copy of the printed and physically signed documents. If you, however, wish to request paper copies of these documents sent to you electronically, you can write back to the sender.

Withdrawing your consent
At any point in time during the course of our business relationship, you have the right to withdraw your consent to receive documents in electronic format. If you wish to withdraw your consent, you can decline to sign a document that we have sent to you and send an email us informing us that you wish to receive documents only in paper format. Upon request from you, we will stop sending documents using Zoho Sign electronic signature system.

To advise Elmira Studio of your new email address
If you need to change the email address that you use to receive notices and disclosures from us, write to us.

System requirements
Compatible with recent versions of popular browsers such as Chrome, Firefox, Safari, and Edge. Zoho Sign is also available on iOS and Android devices.