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Polynucleotide Consent
Medical Questionnaire

Terms of your treatment

I confirm that I have been informed that:

Plinest® is an injectable product designed to improve skin health and appearance. It contains polynucleotides, derived from trout sperm. Polynucleotides are clinically proven to stimulate the biological regeneration of the skin architecture, including collagen, elastin, hyaluronic acid, blood vessels, pigment, and supporting fat cells. 

Treatment with Plinest®is indicated to improve skin texture, improve skin discoloration, skin tone, fine lines, hydration and radiance. Plinest®can also be used to improve the appearance of scars. 

I understand the treatment involves multiple injections with a fine needle, of micro-doses into the surface of the skin. A blunt-tipped cannula may also be used subject to the preference of my practitioner and the area to be treated. 

I understand three to four treatments 3 weeks apart are required to achieve optimum results and optimum longevity. 

I understand to maintain results, a further treatment is recommended every six months. I have been advised that there are alternatives to this procedure available, including the acceptance of my present condition. 

Expected outcome 

The treatment is expected to improve skin appearance and quality, it is often the case that some improvement can be seen within 4 weeks, with continued improvement over 6-12 weeks. Outcomes are dependent on biological responses and subject to lifestyle factors which will vary between individuals. 

I understand that whilst I have been advised as to a probable result, this should not be interpreted as a guarantee. 

Common Side Effects, Associated with the Injection 

● Pain or stinging sensation when the injection is performed 

● Localised swelling, redness, and or tenderness which can take up to 72 hours to settle 

● The injected product will be visible as small bumps in the skin temporarily, usually settling within 12-72 hours. You may be able to feel bumps in the skin for a few days. 

● Bleeding at the sites of injection which may leave pin prick marks 

● Bruising 

● Itching or a sensation of heat 

Common side effects are described as mild to moderate, all are expected to be temporary and generally settle within hours or days. Bruising can take up to two weeks to resolve. 

I understand, whilst not expected, it is possible that the reactions described may inhibit my confidence to attend work or social events. I have been advised to schedule treatment allowing time for common reactions such as bruising, bumps, pin prick marks, and swelling, to settle. Uncommon side effects associated with injections; 

● Infection

● Inflammation 

● Skin discoloration 

● Allergic or sensitivity reaction*may be associated with topical antiseptics or anaesthetics. 

● Persistent lumps, nodules, or papules* reported with similar products 

I understand that though complications are uncommon, they do sometimes occur. I understand individual experiences vary. 

I understand if I suffer any adverse reactions that are not expected, or concern me, I must contact the clinic. An appointment will be made for me to be seen. The clinic cannot take responsibility for complications or results that have not been reported, assessed, documented, and managed in a timely fashion. 

I confirm that the medical history form has been completed truthfully and I am fully aware that withholding medical information may be detrimental to the safe and optimal outcome of any treatment. If there are any changes in my medical history, I must inform the practitioner. 

I understand pre and post-treatment photographs will be taken as a necessary part of my medical record and unless specific permissions are given, will be maintained as confidential. 

I understand in certain circumstances it may be necessary to share medical records with my GP or specialist, and I will be advised if such circumstances arise. 

I confirm I have been provided with and taken time to read the following written information which I have understood and accept;. 

● Treatment information and aftercare instructions 

● Consent form 

● Clinic Terms and Conditions 

I am able and agree to follow the aftercare and follow-up instructions and understand this reduces the risk of adverse reactions and helps ensure optimum results. 

I am satisfied that treatment with Plinest® has been explained comprehensively and that the possible risks and benefits 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 and understanding, before deciding to proceed with the agreed treatment plan. 

I have been advised of the cost per treatment as per the clinic price list and accept the terms of payment as per the clinic policy (terms and conditions)

My medical practioner may use pictures taken before and after my treatment for the follwing purposes. I have seen these pictures and agree or disagree with their use as follows (please tick appropriate boxes)​

Scientific purposes

Media purposes

I certify that I have read and fully understand the above consent form, I have understood the post-injection recommendations and undertake to observe them.

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