the Skin Edit

2. Previous Hair & Scalp Treatments

Please check any treatments or products you currently use or have previously used:

Minoxidil (Rogaine)Finasteride or dutasteridePRP therapyLow-level laser/light therapy (LLLT)MicroneedlingHair mesotherapyHair transplant / FUEOther professional or medical hair/scalp treatment

Please provide relevant dates, products or details

3. About VANTIS Hair

VANTIS Hair is a cosmetic hair and scalp-conditioning product intended for external use. It may be recommended as part of a professional cosmetic hair/scalp program and/or as ongoing home care. The formulation contains cosmetic conditioning ingredients including niacinamide, caffeine, Copper Tripeptide-1, Sodium PCA, ectoin, hyaluronic acid, allantoin, pantothenic acid, trehalose, hydrolyzed eggshell membrane extract, propolis and selected botanical ingredients.

Important: VANTIS Hair is a cosmetic product, not a medication or medical treatment. It is not intended to diagnose, treat or cure alopecia, hormonal hair loss, nutritional deficiencies, scalp disease or another underlying medical condition associated with hair loss.

The program is intended to support the cosmetic appearance, moisture, condition and overall quality of the hair and scalp. Individual experiences vary, and no specific degree of improvement, timeframe or outcome is guaranteed.

5. Safety & Use Acknowledgement

VANTIS Hair is intended for external cosmetic use only and contact with the eyes should be avoided.I will follow the manufacturer's and/or clinic's approved directions for use.I understand cosmetic products can cause sensitivity or irritation and I will discontinue use and contact the clinic if an unexpected reaction occurs.I understand the formula contains propolis (bee-derived), hydrolyzed eggshell membrane extract, botanical ingredients, lemongrass leaf oil, alcohol and cosmetic preservatives.I am responsible for informing my practitioner of known allergies, sensitivities, scalp conditions and products/medications before beginning the program.I understand this consent does not authorize injection, implantation or use of VANTIS Hair in a manner inconsistent with the manufacturer's directions or cosmetic positioning.

6. Cosmetic Goals, Expectations & Medical Referral

Depending on the individual, cosmetic changes may include hair that appears healthier or better conditioned; improved softness, smoothness, moisture or hydration; improved scalp comfort; and improvement in the overall appearance, fullness or volume of the hair.

I understand that age, genetics, lifestyle, hair-care practices, consistency of use, starting hair/scalp condition and underlying health factors may influence my experience. Improvement in the appearance of fullness or overall hair quality does not necessarily represent new hair growth.

I understand that unexplained, sudden, significant or persistent hair loss, scalp disease or other concerning symptoms should be assessed by a physician or other qualified healthcare professional. VANTIS Hair does not replace medical diagnosis or treatment.

7. Photo & Video Progress Documentation Consent

Photo and video documentation is optional. My choice regarding photography or video will not affect my ability to receive the VANTIS Hair program or other clinic services.

Confidential clinical progress documentation

Standardized before-and-after photographs and/or short video may be used to document my starting hair/scalp appearance, monitor cosmetic changes and support follow-up assessment. Clinical documentation will be retained as part of my confidential client record.

YES — I consent to before-and-after photographs for confidential clinical progress documentation.YES — I consent to before-and-after video for confidential clinical progress documentation.NO — I do not consent to photographs or video for clinical progress documentation.

Optional educational / marketing use

This permission is separate from clinical documentation and program consent. Only approved images/video may be used for clinic or VANTIS educational, website, social media or marketing purposes.

YES — I authorize approved before-and-after photographs for educational/marketing use.YES — I authorize approved before-and-after video for educational/marketing use.NO — I do not authorize photographs or video for public-facing use.

Client initials

8. Client Consent

I have provided accurate information regarding relevant allergies, sensitivities, scalp conditions and products/medications I am using.I have had the opportunity to ask questions about VANTIS Hair and the intended cosmetic purpose has been explained to me.I understand the difference between supporting the cosmetic appearance and condition of the hair/scalp and treating a medical hair-loss condition.I understand that individual results vary and no specific outcome has been promised or guaranteed.I voluntarily consent to the professional use and/or recommendation of VANTIS Hair as described in this form.

Client name / typed signature

Date

By typing my name in the client signature field, I acknowledge that it represents my electronic signature and confirms my consent.

9. For Clinic Use Only

Client does not need to complete this section

Professional service performed, if applicable

VANTIS Hair application/use recommended

VANTIS Hair Lot/Batch #

Expiry / PAO

Date product opened

First application date

Application method / amount used

Follow-up date

Practitioner/technician notes

Home-care instructions provided — YesBaseline photo/video captured — YesReaction observed — Yes

VANTIS Hair Rejuvenation Program
Intake, Acknowledgement & Consent

1. Client Information

2. Previous Hair & Scalp Treatments

3. About VANTIS Hair

4. Allergies, Sensitivities & Scalp Screening

5. Safety & Use Acknowledgement

6. Cosmetic Goals, Expectations & Medical Referral

7. Photo & Video Progress Documentation Consent

8. Client Consent

9. For Clinic Use Only

VANTIS Hair Rejuvenation ProgramIntake, Acknowledgement & Consent

1. Client Information

2. Previous Hair & Scalp Treatments

3. About VANTIS Hair

4. Allergies, Sensitivities & Scalp Screening

5. Safety & Use Acknowledgement

6. Cosmetic Goals, Expectations & Medical Referral

7. Photo & Video Progress Documentation Consent

8. Client Consent

9. For Clinic Use Only

VANTIS Hair Rejuvenation Program
Intake, Acknowledgement & Consent