Consent and consultation form for patients treated with Polynucleotide treatments Name * First Name Last Name Address * Email * Contact Number * Do you have any known allergies or history of Anaphlaxis? * Is there any chance of pregnancy? * Yes No Are you breastfeeding? * Yes No Are yo taking any regular medication (including over the counter medicatiions) * Yes No Are you allergic to fish? * Yes No Have you any allergies? If yes, please note below and inform your practitioner Have you been diagnosed with any condition or currently receiving treatment from a health care professional? Yes No The nature of this Procedure, the possible complications and risks, as well as the possible benefits of the Procedure, the alternatives to the Procedure and the risks and benefits for those alternatives have been explained to me in language and using terminology that I understand. My Service Provider has personally answered all of my outstanding questions about the procedure. * I consent I fully understand that this Procedure is an elective aesthetic procedure, and that there is no emergency medical condition that requires that I have the Procedure. * I consent I understand that the Procedure may not be effective. I have been advised that I may need several treatments for this Procedure to be effective. * I consent I understand that after the Procedure, I may experience side effects such as pain, discomfort and tingling, burning, swelling, bruising, Erythema, itching, and swelling, which may be temporary or permanent. * I consent I understand that I will need certain post-Procedure care. I will be dutifully responsible in being strictly compliant with the recommendations from my Service Provider. * I consent I must immediately report any unusual symptoms, know to me, to my Service Provider and be especially aware of any slight nature or prominence of persistent chills or fever, redness or increased warmth, excessive bruising or swelling at the site of the injection, fatigue, lethargy, decreased appetite, jaundice {yellowing of skin or the whites of the eyes), dark urine, unusual severe itchiness or abdominal pain. * I consent I give my healthcare professional permission to use data about my treatment for research purposes. understand that my name and personal identifying information will remain confidential, unless I give written permission to disclose this information. * I consent Declaration of Consent I confirm that my treating practitioner has: Provided me with sufficient information about the treatment detailed overleaf in order to make an informed decision which have included all possible associated risk. Given me the opportunity to ask all remaining questions I may have about the treatment, and has answered them to the best of their ability – Given me the time to consider the treatment detailed overleaf – Received the relevant medical history information from me to the best of my knowledge I therefore consent to receiving the described treatment by my treating practitioner. I confirm that the history I have provided is accurate and complete. I understand that by withholding any information may be detrimental to my health and safety during this procedure. By clicking this I consent to receiving the described treatment by my treating practitioner. Date Signed * MM DD YYYY Thank you!
