AMEELA POLYNUCLEOTIDES CONSENT FORM AMEELA POLYNUCLEOTIDES CONSENT Form To the patient: Name First Date of birth(Required) DD slash MM slash YYYY Untitled(Required) I have received a consultation with a doctor, and I agree to carry out the treatment which involves injecting a Polynucleotide gel into the periorbital area or mid and lower face area for bio-revitalization and tightening effect in the treatment area. Untitled(Required) I am aware that while typically only one to two treatments are required, depending on the amount of skin laxity and skin condition, additional treatments may be necessary. Untitled(Required) I understand the treatment can be repeated after 14-30 days. Untitled(Required) I understand that whilst results desired and expected have been discussed, outcomes vary between individuals and cannot be guaranteed. Untitled(Required) I understand that a follow-up is required after two weeks, and that photographs can be taken before, during, and after treatment for clinical documentation, and the doctor will use the photos for scientific and procedural contexts only, preserving my anonymity. Untitled(Required) I have been informed about the treatment, the procedure, indications, expected results, and possible side effects/ complications. Untitled(Required) I am informed that possible side effects, though unlikely, could be mild allergic reactions to the product. Untitled(Required) I understand that I may experience swelling, redness, tenderness, headache, pain and/or bruising after treatment, but these symptoms will usually pass in 1-2 weeks. In rare cases, these symptoms last longer, and although injection treatments in most cases do not cause allergies or complications, I have been informed that there is no guarantee against this. You have the right, as a patient, to be informed about your condition and the recommended cosmetic, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. Untitled(Required) I have been informed that certain drugs, diseases, and conditions can have a negative effect on the treatment, and we have discussed this issue thoroughly. I certify that I fully informed the doctor correctly and to the best of my knowledge of my full medical history and status. I understand that withholding medical information could lead to complications or problems that may have been prevented if that information were known prior to my procedure. Untitled(Required) I have been informed that the results may vary. Untitled(Required) I am undergoing treatment at my own free will and agree that this procedure is performed for cosmetic reasons and that no guarantee is given regarding the exact results after the treatment. Untitled(Required) I agree to follow the instructions given to me by the doctor to the best of my ability before, during, and after the above-mentioned cosmetic procedure and will notify the doctor who carried out the procedure of any problems fol lowing the procedure. Untitled(Required) I understand and agree that any dispute or litigation with respect to the treatment or procedure of the above will be heard and settled in the city in which the procedure occurred in the United Kingdom, and the laws of England and Wales shall govern all aspects of such dispute or litigation. Untitled(Required) I certify that the doctor carrying out the procedure has discussed the procedure with me to my satisfaction; this form fully explained to me, that I have read it or have had it read to me, that the blank spaces have been filled in, and that I understand its contents. I have been given an opportunity to ask questions about my condition, alternative forms of anaesthesia and treatment, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I believe that I have sucient information to give this informed consent. Consent(Required) A copy of this form is avaliable to you, please ask. Your consent and authorization to receive the treatment are totally voluntary. The nature of this procedure, the alternative methods possible as well as the complications were all explained to you. No guarantee of results has been promised to you. I accept the clinic terms and conditions. I am satisfied treatment with dermal fillers has been explained comprehensively and that the possible risks and side effects associated with the treatment have been fully discussed and understood. I have taken sufficient time to process and consider the information provided and any questions I had have been answered to my satisfaction, before making a decision to proceed with the agreed treatment plan. A copy of this form is avaliable to you, please ask. Your consent and authorization to receive the treatment are totally voluntary. The nature of this procedure, the alternative methods possible as well as the complications were all explained to you. No guarantee of results has been promised to you. I accept the clinic terms and conditions. I am satisfied treatment with dermal fillers has been explained comprehensively and that the possible risks and side effects associated with the treatment have been fully discussed and understood. I have taken sufficient time to process and consider the information provided and any questions I had have been answered to my satisfaction, before making a decision to proceed with the agreed treatment plan. Client SignatureDoctor SignatureDate(Required) DD dash MM dash YYYY